Experts Take a Hard Look at an Influential Journal Article on Gender-Affirming Care

Jan. 16, 2025
Medical-legal experts examine a journal article influencing gender-affirming care

At a time when the issue of gender-affirming care has become embroiled in legal and political battles, a team of medical-legal experts has published an article that takes a critical look at a clinical journal article that has been used by partisans to denounce gender-affirming care.

Writing in the Perspective section of The New England Journal of Medicine on Jan. 15 in an article entitled “The Future of Gender-Affirming Care—A Law And Policy Perspective on the Cass Review,” Daniel G. Aaron, M.D., J.D., and Craig Konnoth, J.D., write that a clinical journal article frequently cited as authoritative around criticisms of gender-affirming care for children and teens, is itself deeply flawed, and needs to be examined critically in the context of the current debate. Aaron is an associate professor of law at the University of Utah S.J. Quinney College of Law (Salt Lake City), and also holds an M.D. degree from the Boston University School of Medicine. Craig Konnoth is the Martha Lubin Karsh and Bruce A. Karsh Bicentennial professor of law at the University of Virginia School of Law (Charlottesville).

The article the authors are referring to is a publication known as “The Cass Review.” It is a report commissioned by the National Health Service (NHS) of Great Britain, and authored by a physician, Dr. Hillary Cass, in her capacity as “Chair of the Independent Review of gender identity services for children and young people” in the United Kingdom.

Authors Aaron and Konnoth write that, “In April 2024, a 388-page report commissioned by England’s National Health Service (NHS) concluded that “there is not a reliable evidence base upon which to make clinical decisions” regarding gender-affirming care (GAC). Called the ‘Cass Review’ for Dr. Hilary Cass, who led the process, it has been used to justify banning GAC until randomized, controlled trials (RCTs) are conducted. In England, the NHS has instructed gender clinics serving adults to ‘pause’ accepting new patients under 18 years of age, banned the use of puberty blockers, and shuttered the main pediatric GAC clinic. And in the United States, the Cass Review has been used to defend new state bans on GAC for young people — including one in Tennessee that currently sits before the U.S. Supreme Court.”

All that said, Aaron and Konnoth note that “An array of criticisms have been leveled at the Review. Our concern here is that the Review transgresses medical law, policy, and practice, which puts it at odds with all mainstream U.S. expert guidelines. The report deviates from pharmaceutical regulatory standards in the United Kingdom. And if it had been published in the United States, where it has been invoked frequently, it would have violated federal law because the authors failed to adhere to legal requirements protecting the integrity of the scientific process.”

Indeed, they write, “The Review calls for evidentiary standards for GAC that are not applied elsewhere in pediatric medicine. Embracing RCTs as the standard, it finds only 2 of 51 puberty-blocker and 1 of 53 hormone studies to be high-quality. But more than half of medicines used in pediatrics have historically been prescribed off-label on the basis of limited evidence. Physicians have noted that requiring robust evidence for pediatric use of every drug would greatly limit drug treatments for children, who are already considered by researchers to be ‘pharmaceutical orphans.’ Indeed, Cass has herself admitted that RCTs are probably infeasible in the GAC setting; ‘they’re difficult studies to design because you can’t blind people,” she notes, since patients will see bodily changes when given GAC-related pharmaceuticals.’”

And the profound concern the writers express in the article is that publications like the Cass review could be used to shape policy in this country around gender-affirming care, to the detriment of transgender-identified children and youth. As they write, “Mainstream medical views have shifted on both abortion access and care of intersex people. But the Cass Review suggests that some actors continue to focus on policing gender in the context of transgender rights. Indeed, U.S. GAC bans exempt intersex surgeries — which suggests that such laws are designed not to protect children, but to enforce the gender binary. The Cass Review’s unacceptable departures from medical law and policy are best understood in a similar way.”

 

 

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