Yale Researchers, International Experts Release New Paper Rebuking Cass Review

A new study released from the Integrity Project at Yale strongly rebuked inaccuracies in the Cass Review targeting trans care.

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Note: This edition of Erin In The Morning is brought to you by Mira Lazine, who is guest writing for Erin In The Morning. Mira Lazine is a freelance journalist covering LGBTQ+ issues, politics, and science.

On Monday, a team of nine international experts on transgender care drafted a 39-page response paper to the Cass Review. The paper argues that the Cass Review, including the additional York Reviews, has numerous methodological problems in both how it was conducted and how it interprets its data, and that it has been grossly misused by governmental bodies across the world in justifying bans on gender affirming care, especially for minors. The Cass Review is a review of the literature on puberty blockers’ effects on transgender youth conducted by Dr. Hillary Cass, a researcher who has no prior experience working with transgender youth, and who has consulted with Ron DeSantis appointed Florida medical board members in establishing the Review. In addition to the main document outlining clinical recommendations, it also has several systematic reviews conducted by researchers from the University of York. The Review has been used to justify bans on puberty blockers in England, and has been cited in court cases restricting gender affirming care across the United States.

“The Review repeatedly misuses data and violates its own evidentiary standards by resting many conclusions on speculation. Many of its statements and the conduct of the York [systematic reviews] reveal profound misunderstandings of the evidence base and the clinical issues at hand,” says the paper. “The Review also subverts widely accepted processes for development of clinical recommendations and repeats spurious, debunked claims about transgender identity and gender dysphoria. These errors conflict with well-established norms of clinical research and evidence-based healthcare. Further, these errors raise serious concern about the scientific integrity of critical elements of the report’s process and recommendations.”

The article is entitled “An Evidence-Based Critique of ‘The Cass Review’ on Gender-affirming Care for Adolescent Gender Dysphoria,” and is authored by Dr. Meredithe McNamara, Dr. Kellan Baker, Dr. Kara Connelly, Dr. Aron Janssen, Dr. Johanna Olson-Kennedy, Dr. Ken C. Pang, Dr. Ayden Scheim, Dr. Jack Turban, and Dr. Anne Alstott. It was announced both by Turban in a post on Twitter, as well as on the Yale Law School’s website. Both McNamara and Alstott are professors at Yale who co-founded the Integrity Project, a project that aims to provide legal justice to marginalized peoples.

The core of the paper is divided into seven sections that each tackle a different element of the Review. The first section focuses on how the Review actually is compliant with established standards of care recommendations for providing legal protections for gender affirming care. The authors compare it to the World Professional Association for Transgender Health’s (WPATH) eighth rendition for standards of care and the Endocrine Society clinical practice guidelines, finding that recommendations for individualized and evidence based care are consistent across these different documents. The authors state, “the Review does not conclude that gender-affirming medical care for adolescent gender dysphoria should be banned. Thus, it should not be cited in support of bans on medical treatments for gender dysphoria.”

The second section focuses on the Review’s failure to follow typical academic standards in conducting systematic reviews. They compare the systematic reviews seen within the Cass Review to the standard Grading of Recommendations Assessment, Development and Evaluation (GRADE) metric. They find that the Review relies on its own standard for evaluation which uses subjective evaluations of evidence quality and ignores the many other components of a good systematic review – such as evaluating the positives of treatment and comparing that to the negatives of being denied treatment. They also state that the Review ignores the desires of those patients surveyed. In essence, they argue that Cass ignores standard professional practice and improperly focuses on unachievable “high quality” evidence for gender affirming care.

Section three discusses how the Review holds gender affirming care to a much higher standard than what is seen for other areas of pediatric medicine. The authors detail how the Review holds pediatric gender affirming care to a standard that “no other area of pediatrics is held to.” In other fields of medicine, it is routine for medical professionals to make decisions based on the best available evidence without there being high quality research on the topic in order to accommodate complex medical needs. The Review, however, does not do this, and instead relies on a strict concept of care that is alien from normalcy in the medical industry.

The fourth section argues that the Review misinterprets much of its own evidence, leading to faulty interpretations of how to care for transgender youth. The biggest example they focus on is the inaccuracy of the claim that there is an “exponential” increase in referrals in recent years, something that has been used by opponents to transgender care to sound alarm that care is being rushed without evaluating the evidence, something that the authors emphasize is not accurate. They describe how the increases actually show that not enough transgender youth in the United Kingdom are receiving their care. Section five expands on the fourth by describing what the Review gets wrong in terms of the evidence for gender affirming care. These inaccuracies include problems with how the Review claims that social transition and puberty blockers can be harmful, claims that both desistance and detransitioning rates are incredibly high, and claims that ‘social contagion’ is actually a real phenomena. The authors meticulously detail the problems with each of these ideas, pointing out how the evidence does not support them and has been strongly misrepresented.

Section six builds off the established claims of the Review and argues that Cass ignores “key findings in the extant body of literature.” The authors say that the York Review protocols are inaccurate, that the literature search is problematic and outdated, and that they used their tools inappropriately. One particularly egregious issue is that, when discussing the appraisal tools used, the York Reviews cited a commentary on the scale and not the scale itself, with the authors of that tool arguing that those who cite it this way likely have not actually read the proper scale. Other claims by the authors of An Evidence-Based Critique include a lack of clear expertise in transgender care on the part of the authors of the York Reviews, contradictory findings and conclusions within the systematic reviews, and problems with their methods being entirely subjective and without validation in the broader literature.

The final section builds off all six other sections in stating that “the Review’s relationship with and use of the York SRs goes against the grain of conventional processes used widely in evidence-based medicine.” They contrast what is done in the Review to standards for establishing a clinical recommendation based on systematic reviews, and the lack of expertise in drafting things like the research protocols for evaluating the evidence of transgender care. They also detail how the protocol that was registered for the York Reviews was not followed, echoing previous concerns in the paper about bias on behalf of Cass and her team.

This paper shines a new light on interpretations for the Cass Review, suggesting that it’s based on low quality work and has been falsely interpreted in legal proceedings across the world. The lack of expertise from Cass herself contrasts with the expertise of the authors of the paper, all of whom represent institutions across the world that have decades of research and clinical practice on transgender individuals. Legal decisions made using the Cass Review need to be reevaluated in light of the sweeping critiques found within this paper.