Gender affirmative guidelines just an echo chamber, says UK expert

The British paediatrician who carried out a world-leading review of care models for children experiencing gender distress says gender care guidelines are an ‘echo chamber’ with little evidence.

Transgender healthcare is under scrutiny internationally. Picture: AFP

The British paediatrician who carried out a world-leading review of care models for children with gender distress has criticised trans healthcare guidelines as an “echo chamber” based on weak evidence that show no efficacy in alleviating the psychological distress of young people.

Hilary Cass, who led the landmark review of gender-affirming care that prompted the UK’s Nat­ional Health Service to ban the prescription of puberty blocker hormone drugs for children under 16, said that gender affirmative care guidelines around the world had not followed an evidence-based approach, and “sort of copy and paste off each other” in order to justify their medical approaches.

Dr Cass, a former president of the UK’s Royal College of Paediatrics and Child Health, participated in a panel live from the UK on Tuesday night, which was hosted by Australian psychiatrist Phillip Morris, the president of the ­National Association of Practising Psychiatrists, one of the first bodies to call for caution on experimental medical treatments and greater wholistic psychotherapy for young people with gender distress.

Dr Cass criticised the activist World Professional Association for Transgender Healthcare for essentially suppressing evidence that the standards of care it ­devised were not evidence-based and showed no proof of alleviating the distress of children.

These standards are followed by most of Australia’s major children’s hospitals that all frequently prescribe puberty blockers and hormone treatments to children and teenagers. Dr Cass noted in her independent report handed down in April that WPATH had been “highly influential in directing international practice, although its guidelines were found by the University of York’s appraisal to lack developmental rigour and transparency”. The Cass report included an appraisal by the University of York that analysed international gender affirmative care guidelines, including those of the Royal Children’s Hospital Melbourne. The review found the RCH’s guidelines similarly lacked rigour and independence.

“The evidence base is weak … international guidelines have for the most part not followed standard evidence-based approaches,” Dr Cass told the Australian seminar. “And it has influenced most other international guidelines. There is a sort of echo chamber of sort of copying and pasting off each other. The only guidelines that have taken an independent and evidence based ­approach are the Swedish and the Finnish guidelines.”

The Cass independent Review was commissioned following ­patient and whistleblower complaints that prompted the closure of London’s flagship Gender Identity Development Service run by the Tavistock and Portman NHS Foundation Trust. Dr Cass said that complex clinical presentations including mental health ­issues and autism among children who presented at the GIDS were “overshadowed” when the children presented with gender distress. The pediatrician concluded that puberty blockers rather than acting as a “pause button” allowing children time to explore their identity, seem to lock them into a medicalised treatment pathway.

Dr Cass’s final report endorsed a ­fundamental shift in approach away from medical intervention towards a holistic model that ­addresses other mental health problems the children may have.

The report concluded that children had been let down by a lack of research and “remarkably weak” evidence on medical interventions in gender care. She wrote in the British Medical Journal that gender medicine’s pillars were “built on shaky foundations”, expressing concern at the unknown long-term cognitive and physical impacts of puberty blockers.

Puberty blockers are now only able to prescribed as part of clinical trials in the UK, and several other European countries that have moved to roll back the experimental approach espoused by the trans activist group World Professional Association for Transgender Health.

All of Australia’s children’s hospitals including most of the country’s state health ministers have rejected the relevance of Dr Cass’s report to Australia for reasons that appear spurious given the fact that Dr Cass’s report examined gender affirming care models internationally, and that the deep research carried out by the independent review into puberty blockers is clearly relevant beyond the UK.

Dr Cass’s report said there was “no evidence” puberty blockers allowed young people “time to think” by delaying the onset of puberty — the original rationale for their use. It found the vast majority of children who began taking puberty blockers progressed to taking cross-sex hormones as they grew older, despite the fact that desistance from trans identification among teenagers was relatively common.