Over the last decade, the U.K. and the U.S. have witnessed a growing moral panic surrounding the presence of transgender people. Particularly concerning children, this panic has been fuelled by years of sensationalist media coverage and political manoeuvring. Misinformation has spread, with unfounded claims suggesting that transgender children are victims of a "psychic epidemic" or "social contagion," that they are being forced into transitioning against their will, or that they are rushed into medical treatments.

In 2020, amidst campaigns to revoke legal protections and healthcare services for transgender individuals, the National Health Service (NHS) in the U.K. initiated the Cass Review. This review of gender services for children in England, led by retired paediatrician Hilary Cass, assessed current research on transgender healthcare for those under 18, consulted stakeholders, and provided recommendations for NHS England.

Released in April, the final Cass Review report voiced concerns about the rising number of young transgender individuals seeking treatment and claimed that the evidence supporting gender-affirming medical interventions was "remarkably weak." For example, it suggested that puberty blockers—medications used to delay puberty—should only be prescribed within clinical trials. The report also raised concerns about social transition for younger children, which involves non-medical decisions like changing names, clothing, or pronouns.

Although the Cass Review has been hailed by the U.K. media, politicians, and some medical professionals as a model of objective inquiry, its most contentious recommendations appear to be based more on bias than on evidence. Rather than supporting young people, the review has inflicted significant harm on children, their families, democratic discourse, and broader scientific principles. A critical assessment of the report's context and findings is urgently needed.

Since its inception in 2020, the Cass Review has been marked by its anti-trans stance. It deliberately excluded transgender people from key roles in research, analysis, and oversight, and it sidelined many practitioners with expertise in transgender healthcare. Instead, the project prioritized and sympathized with anti-trans viewpoints, including those of professionals who deny the existence of transgender children. Former U.K. Minister for Women and Equalities, Kemi Badenoch, who has a record of hostility toward transgender people despite her role in promoting equality, boasted that her involvement made the Cass Review possible.

Medical experts and academics from various fields have heavily criticized the Cass Review's methodology. Criticism has focused on the impact of bias, double standards in interpreting data, poor scientific rigor, methodological flaws, and the failure to adequately support its claims. For instance, while existing literature highlights numerous benefits of social transition with no credible evidence of harm, the Cass Review cautions against it. Additionally, it downplays the documented advantages of adolescent medical transition while emphasizing risks based on weaker evidence. One warning about impaired brain development, for example, relies on a single speculative study involving female mice. Meanwhile, extensive qualitative data and clinical consensus are largely ignored. These flaws help explain why the Cass Review's recommendations diverge from previous academic reviews and guidance from major medical organizations like the World Professional Association for Transgender Health (WPATH) and the American Academy of Pediatrics.

WPATH experts have criticized the Cass Review's "selective and inconsistent use of evidence," noting that the recommendations often do not align with the data presented. Leading transgender medical care specialists from the U.S. and Australia argue that the review obscures key findings, misrepresents its data, and misapplies the scientific method. For example, the Cass Review claims that the increase in referrals to England's child and adolescent gender clinic during the 2010s was "much faster than expected." However, this rise has not been exponential, and the 5,000 referrals in 2021 represent only a small fraction of the estimated 44,000 transgender adolescents in the U.K. based on 2021 census data.

The Cass Review received widespread support from the U.K. media and was quickly endorsed by the two major political parties, the Conservatives and Labour. It was celebrated as evidence that transgender rights had "gone too far," validating years of harmful propaganda. Many politicians and commentators failed to acknowledge the dangers and harm embedded in the review's recommendations. These harms are already being felt acutely by transgender children and adolescents across the U.K. and beyond. The Endocrine Society has warned that "misinformation about gender-affirming care is being politicised."

Transgender youth in the U.K. now face numerous abuses and humiliations encouraged and legitimised by the Cass Review. Families, schools, and social services have been advised against supporting social transitions, a move that will leave transgender children in prolonged situations of rejection and shame. New gender services in England are not allowed to offer affirming care and instead focus on invasive and exhaustive assessments. Being transgender is treated as an inherent problem rather than a legitimate identity.

Currently, there is no pathway for transgender individuals under 18 in the U.K. to begin medical transition through the NHS. Puberty blockers are theoretically available only through a proposed clinical trial that has yet to be designed, let alone launched. Whether this trial ever happens is irrelevant; it serves as a tool for the NHS and the U.K. government to deflect accusations of banning adolescent healthcare.

In May, the outgoing Conservative government used rarely invoked emergency powers to criminalise the possession of privately sourced puberty blockers. Following the Labour Party's electoral victory, the new Health Minister, Wes Streeting, supported the ban, citing the Cass Review. However, the criminalisation applies only to transgender youth, as cisgender children and adolescents can still legally access puberty blockers for the same purpose—pausing puberty—and the same medications continue to be prescribed for other conditions.

It is estimated that over 1,000 transgender adolescents in the U.K. now find their treatment illegal. Families risk up to two years in prison for supporting their child's continued access to private medication. These adolescents face a forced medical detransition, compelling them to undergo the puberty they fought to avoid. Their alternatives are to leave the country or take greater risks by continuing blockers under the threat of prosecution or using alternative medications with more severe side effects. Families report that fear is causing transgender children to skip routine hormone monitoring and disengage from broader healthcare services.

Transgender youth in the U.K. and worldwide have faced immense stress for years, enduring increasing hostility, persecution, and violence. Transgender communities and supportive families are now urgently trying to draw attention to the current threats to young transgender people's safety. In July, a group of transgender teenagers staged a four-day sit-in at NHS England headquarters, protesting under the slogan "trans kids deserve better." The systemic power imbalance that leaves transgender youth vulnerable in the U.K. was once again evident, as the U.K. media largely ignored this unprecedented action.

Transgender children now need stronger allies from the wider public, as well as from academic, medical, and political institutions. We must unequivocally condemn the significant failings of the Cass Review, acknowledge the harm it has already caused, and work actively to ensure all children have access to healthcare free from prejudice.

Read the full report on the Scientific American website.

First published: 27 August 2024

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