The review included:

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• An assessment of all aspects of pediatric gender care services at the Tavistock Clinic’s Gender Identity Development Service (GIDS), the only pediatric gender clinic in operation in the U.K., between 2009 and 2020.

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• A series of systematic reviews, conducted by the University of York, of published evidence relevant to epidemiology, clinical management, models of care and outcomes, as well as an appraisal of international guidelines and an international survey of gender clinics to look at evidence application and clinical practice in other comparable health systems. 

 

The first findings, The Interim Cass Review, were released in February 2022, followed by the Final Report in April 2024. 

 

WHY THE CASS REVIEW WAS COMMISSIONED

The purpose of the Review was to assess current services and to develop a new policy for future treatment of gender dysphoria. Disagreement among clinical professionals had reached a critical point:

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Some Tavistock pediatric gender therapists had resigned their posts or made formal complaints about how care protocols were influenced by outside groups and that experimental drugs were prescribed to minors without true informed consent.

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• Parents and advocacy organizations were expressing grave concerns about fast-tracking kids to medicalization.

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• A young woman, Kiera Bell, brought — and won — legal action against GIDS for misdiagnosing her distress as gender dysphoria, resulting in permanent physical harm.

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• There were incredibly long waiting lists due to an exponential increase in adolescents presenting with gender distress and requesting medical intervention.

 

WHAT CASS REVEALED ABOUT U.K. PEDIATRIC GENDER CARE

Teams at GIDS — like their counterparts in U.S. gender clinics — were following guidelines issued by the now-discredited World Professional Association for Transgender Health (WPATH) and the Endocrine Society, based on the Dutch Protocol — practices euphemistically known as “gender-affirming care.” According to The Cass Review, “in 2011, the U.K. trialed the use of puberty blockers in the ‘early intervention study.’ Preliminary results from the early intervention study in 2015-2016 did not demonstrate benefit. The results of the study were not formally published until 2020, at which time it showed there was a lack of any positive measurable outcomes. Despite this, from 2014 puberty blockers moved from a research-only protocol to being available in routine clinical practice and were given to a broader group of patients who would not have met the inclusion criteria of the original protocol.” In light of the exponential increase in referrals, the study aimed to systematically evaluate the approach, quality of care, and outcomes.

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SUMMARY OF KEY FINDINGS FROM THE CASS REVIEW

• The dramatic rise in numbers of gender dysphoria referrals in teens and young people — predominantly girls and young women — was “a result of a complex interplay between biological, psychological and social factors.”

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• Conflicting views on clinical practices created an atmosphere of fear and confusion, so providers were not always following usual care plans for young people presenting with psychological distress.

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• The systematic evidence review revealed the poor quality of published studies, providing no firm basis for making clinical decisions, or for helping children and families make informed choices. 

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• Strengths and weaknesses of the current evidence base for the care of children and young people were often misrepresented and overstated, in both scientific publications and social debate.

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• Controversy took the focus away from the individualized care plans needed.

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• The reasoning for prescribing puberty blockers was weak, with insufficient proof that they reduce gender dysphoria or improve mental health; blockers impact cognitive and psychosexual development and it is known that they diminish bone density and may limit a child’s height (with other physical impacts unknown).

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• No long-term data is available to understand the impacts of giving opposite-sex hormones to minors.

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• Clinicians had no way to determine in advance which children would continue to suffer from gender dysphoria even when treated with blockers and hormones.

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• Medicalization is not the best path to manage gender-related distress in most young people. For “clinically indicated” cases, efforts should be made to address their wider mental health and psychosocial issues before proceeding down the medical pathway.

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• “Innovation” is needed in the field, but effective oversight is required to avoid unproven approaches being introduced into clinical practice.

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• WPATH, the Endocrine Society, and the authors of studies on pediatric gender medicine engaged in the unethical practice of circular referencing, also known as citation laundering, in which they reference their own and each other’s policies or findings (without regard for the quality of evidence) to lend false legitimacy to their claims.

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• Adult gender clinics refused to release their data so no conclusions could be drawn regarding the long term use of hormones (though the refusal speaks volumes).
   

CHANGES IN THE U.K.

• Closure of GIDS: After the publication of the Interim Cass Report in 2022, the NHS announced that they would be closing the GIDS clinic and opening several regional clinics with new, improved clinical protocols.

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• Banning of Puberty Blockers: In advance of The Cass Review - Final Report, the NHS announced in March 2024 that clinicians should stop routine prescribing of puberty blockers in England and Wales. On July 15, 2024, the UK government indefinitely banned the NHS from prescribing puberty blockers to anyone under 18 diagnosed with gender dysphoria.

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• Psychotherapy First: Following the Report’s publication, NHS England published a letter to Hilary Cass — Implementing Advice from The Cass Review — that described how new multi-disciplinary teams would pursue a more holistic approach to treatment, centered on mental health support.

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• Caution in Social Transition in Schools: In December 2023, the U.K. government adjusted their guidance for schools on social transition. They stated that schools “should not proactively initiate action towards a child's social transition.” The Interim Cass Report stated that social transition was “not a neutral act” and recommended great caution. The Final Report unequivocally stated that social transition should be treated with the same caution as prescribing drugs, signaling the end of the common practice of schools unquestioningly using a child’s “chosen” name and whatever pronouns were requested, and letting them use bathrooms and changing rooms based on their “identity” rather than their sex.

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• Follow-Up of GIDS Patients Ordered: Following the Review’s release, the U.K. Health Secretary demanded "full co-operation" by adult gender clinics (which had previously refused to provide data to researchers). Adult services were required to provide records on trans-identifying patients who started their treatment as children, but might later have changed their minds and/or suffered serious physical and mental health problems as a result.

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• Required Professional Training: All staff working with gender-confused children and teens must undergo a “required professional training curriculum and competencies framework.”

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• Adult Gender Care Review: The NHS announced the start of a comprehensive review of adult gender clinic (AGC) services.

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• No First Appointments for Minors at AGCs: Adult gender clinics must proceed with extreme caution when offering opposite-sex hormones to young people and no minor can be seen at an AGC.

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• Language Change: Shortly after publication of the Cass Review, the U.K. Health Secretary announced changes to the NHS Constitution to restore the primacy of biological sex. Phrases like “chestfeeding” and “people with ovaries” will no longer be used. Biologically precise, sex-based language that better describes the medical needs of all patients will be reinstated.

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• Same-Sex Medical Staff for Intimate Care: As a result of Cass, patients in England will be able to request a doctor of the same sex for intimate care under proposed changes to the NHS constitution.

DIAG’S POSITION ON U.S. GENDER CARE FOLLOWING CASS

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ADOPT CASS RECOMMENDATIONS

 

DIAG calls for the U.S. Government to adopt the recommendations of The Cass Review, and form a bipartisan commission to fully investigate the influences in our educational institutions and online, which are driving the exponential increase in young people adopting a “gender identity.”

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We call on the organizations named below to follow the lead of the NHS, and take meaningful steps to safeguard children and vulnerable adults in the United States from harmful sex-trait modification:

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• The American Medical Association

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• The American Academy of Pediatrics

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• The American Psychological Association

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• The Endocrine Society

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• American Academy of Child and Adolescent Psychiatry

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Given that the spike in those seeking interventions for gender-related distress extends to those up to age 25, and that crucial neurodevelopment continues into the mid-twenties, DIAG calls on the groups named above to revise their guidelines for all people aged 25 and under. Our major medical organizations have not been “following the science” on “gender-affirming care” and they need to be held to account. Because these organizations have abdicated their responsibilities, it falls to our elected officials to legislate needed change. 

 

IMPLEMENT SPECIFIC TREATMENT POLICY CHANGES

For those under 18:

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• End the pathologizing of puberty and support all children to go through puberty unimpeded.

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• End the use of puberty blockers for all pediatric purposes other than for treating precocious puberty.

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• Adjust practices to reflect the serious negative impacts of social transition.

 

For those over 18 and over:

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• Provide non-invasive, evidence-based care that respects human biology and does not result in sterilization, anorgasmia, or increased risks of severe health impacts.

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• Offer psychotherapy as the first, and primary, treatment for gender distress.

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• Prioritize identification and treatment of comorbidities.

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• Develop, fund, and provide robust care for detransitioners.
   

EDUCATE THE PUBLIC AND KEY INSTITUTIONS REGARDING HARMS CAUSED

DIAG is committed to informing Dems and the U.S. public in general about the failings and misinformation promoted by:

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• Our major medical organizations and “gender care” medical practitioners

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• The mainstream media

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• Our schools and universities

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• Our elected and appointed officials
   

Countless U.S. young people have been irreversibly harmed, their future options and freedoms stolen, including the potential for biological parenthood, the ability for women to breastfeed, and to experience full sexual function. A dangerously ill-informed and misguided group of clinicians, in whom families across the country placed their trust, need to confront the weak evidence base for the affirmative model and be honest about the science, in the same way that the NHS is doing with the U.K. clinicians.

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Despite the unprecedented thoroughness of the review, U.S. authorities seem determined to ignore or attempt to undermine its findings.

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RELATED RESOURCES​

FAIR: After Cass (YouTube Video)

 

WBUR: Interview with Dr. Hilary Cass 

 

Gender Medicine in the U.S.: How the Cass Review Failed To Land, Jennifer Block, The BMJ