A new report published in The Medical Journal of Australia argues that the UK’s Cass Review should not used as a guide for the care of young transgender people and argues that Australia’s approach to treatment is recognised internationally as best practice.
Its one of a series of reports published in a special edition of journal focusing on gender and health.
“The goal of this special issue is to provide a platform for research and analysis that engages with what gender means for Australian healthcare in a manner informed by evidence, scientific rigour, a quest for equity and justice and, fundamentally, respect for the rights, dignity, and perspectives of affected
populations,” the MJA’s Senior Deputy Medical Editor Dr Elizabeth Zuccala wrote in an accompanying Editor’s choice article.
While the issue covers a wide range of medical issues there are key articles relating to transgender health care including an analysis of the controversial Cass Review and another paper that looks back at previous research undertaken in Western Australia that is now being questioned.
The analysis of the Cass Review, which is authored by multiple Australian researchers, says the UK government’s approach is deeply flawed.
Upon the release of the report the UK government ruled that puberty blocker medication could only be prescribed to to transgender adolescents if it was part of a clinical trial, and to date the UK has not introduced any clinical trials in this area. The review also recommended the restriction of hormone treatments to people under the age of 16 years of age, and wanred against social affirmation of transgender children.
The new paper highlights that the Cass Review has been criticised by expert professional organisations from around the globe, and in peer-reviewed literature, for it’s disregard of international expert consensus, methodological problems, and conceptual errors.
The authors say the contradictions within the Cass Review are striking.
“The Cass Review’s internal contradictions are striking. It acknowledged that some trans young people benefit from puberty suppression, but its recommendations have made this currently inaccessible to all. It found no evidence that psychological treatments improve gender dysphoria, yet recommended expanding their provision.” they highlighted.
They also note that the review found that the use of hormone treatments was already very restricted, and it caused young people distress when they faced long waiting times for treatment, but then made those same treatments harder to access.
They argue that Australia’s approach is superior as it takes a multi-disciplinary approach and focusses on the needs of the patient.
“Gender‐affirming care, as described in authoritative guidelines, is person‐ and family‐centred, holistic, multidisciplinary, and ethically sound.” the researchers state, noting that many of the 32 recommendations made in the Cass Review align with practices already undertaken in the Australian system.
Concern is raised that the Cass Review has led to multiple harmful recommendations and they cite several factors that may have contributed, including a sociopolitical climate that is making increasingly unsafe for transgender people of all ages.
They note that the UK has seen escalating anti-trans hate crimes and growing prejudice, against a backdrop of dehumanising media commentary. Factions of feminist through where trans women are framed as a threat as prominent, and traditional psychoanalytic theories that pathologise gender diversity remain influential.
There is also concern that the review did not adequately involve clinicians with experience in gender care, nor did it adequately consult with people with the lived experience of being transgender.
Adding to the list of flaws in the report are issues of a lack of scope, sufficient evidence and in some cases large blocks of research being omitted.
“The Review report did not include consideration of evidence of gender diversity across cultures. It did not acknowledge the existence of healthy trans children, or trans adults who were once trans children and/or adolescents. It speculated baselessly about causes of gender diversity, from pornography to trauma. The literature on sex‐hormone receptor polymorphisms and trans identity was not discussed at all, which we find to be a surprising omission.” the authors wrote.
The Cass Review is also criticised for focusing on the increasing uptake of treatment in recent years as being a cause for concern.
They note that an increase in awareness of both transgender people in society and the treatment options available would naturally lead to more people looking for assistance, and note that similar sudden uptakes have occurred with other medical treatments that have been introduced in the past, for example the introduction of oral contraceptives for women saw a significant change is their use between 1960 and 1975.
The authors conclude that, “good medicine is guided by the values of the patient, not those of a clinician, politician or commentator.” and the focus should be on providing a pathway that allows the patient’s goal of achieving the optimal quality of life.
They call for future research to continue to be ethically conducted, but also co-designed with people who are transgender. The authors say the Cass Review is lacking expertise and there is great concern on the effects it’s having on transgender people’s medical care.
“The Cass Review, lacking expertise and compromised by implicit stigma and misinformation, does not give credible evidence‐based guidance. We are gravely concerned about its impact on the wellbeing of trans and gender‐diverse people.” they say at the conclusion of the report.
The National Health and Medical Research Council is currently reviewing the Australian standards of care and treatment guidelines for transgender and gender diverse children and developing updated guidelines.
