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Cass Review

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The cover of the final published version of the Cass Review (2024), featuring an AI-generated image of a kid with wonky hands bolted to a wall.
It's a social construct
Gender
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Spectra and binaries
v - t - e

The Independent Review of Gender Identity Services for Children and Young People, more commonly known as the Cass Review or Cass Report, is a 388-page government report on the provision of gender-affirming care to young people in the United Kingdom.[1][2] Commissioned by the NHS as an "independent review" headed by paediatrician Hilary Cass, the report took four years to produce and led to swift, sweeping policy changes (including a ban on puberty blockers) after its release in April 2024.[3][4]:10 As it was a review (and the final report was not itself subject to traditional peer review[5] although that matters less than one may think), it didn't itself produce new evidence.[4]:6

Prior to Cass, one review in this area of medicine was Cornell University's 2018 review by the What We Know Project.[6] Out of nearly sixty studies considered by that review, the Cass Review and its associated systematic reviews for some reason found occasion to reference precisely zero of the same papers. The Cass Review has, predictably given some of its content and background, been well-received by anti-trans lobby groups and activists.[2] Outside the echo chamber inhabited by transphobes, it has been roundly criticised by major medical organisations for its limitations and serious methodological flaws,[7][3] and has been cited as an example of policy-based evidence making.[8][9][10] Despite its flaws, the Cass Review doesn't call for a ban on any of the options that doctors and their patients might pursue.[11]:4–7

Rigging the game[edit]

“”One senior psychiatrist at a gender identity clinic in England told a national newspaper in the UK that the failure to include those with personal or professional experience “had concerned many within the field.” They said: “The terms of referenceWikipedia stated that the Cass Review ‘deliberately does not contain subject matter experts or people with lived experience of gender services’ and Dr. Cass herself was explicitly selected as a senior clinician ‘with no prior involvement … in this area.’ Essentially, ignorance of gender dysphoria medicine was framed as a virtue. I can think of no comparable medical review of a process where those with experience or expertise of that process were summarily dismissed.” WPATH and USPATH agree completely.
—World Professional Association for Transgender HealthWikipedia (WPATH)[12]

Hand-picked from a shortlist of one[edit]

The NHS announced in January 2020 that it was establishing an "independent expert group" chaired by Hilary CassWikipedia to "support a review of puberty suppressants and cross-sex hormones" in paediatric gender care.[13] In September 2020, the NHS announced that Cass would also head this review, which it billed as an "independent review into gender identity services for children and young people."[14] Both press releases hailed her as "Dr Hilary Cass OBE, former President of the Royal College of Paediatrics and Child Health."[13][14] They didn't mention that Cass lacks clinical experience or expertise in caring for trans youth.[15]

The World Professional Association for Transgender Health condemned Cass's appointment as occurring "without any transparent or competitive process" in a statement released after the review's publication in 2024.[15] A freedom-of-information request that same year revealed that Cass was the only candidate considered for the job (from a "shortlist" of one).[16][17]

Tory minister Kemi Badenoch,Wikipedia a DeSantis[18] and Murdoch darling,[19] proudly admitted in a June 2024 tweet that political manipulation paved the way for Cass.[20] According to Badenoch, the review wouldn't have been commissioned under a Labour government, and it was "when the ministers changed" that her party no longer faced "opposition from the system."[20] She said a decisive factor in the production of the Cass Review was "having gender-critical men and women in the UK government, holding the positions that mattered most in Equalities and Health."[20] Cass was not-coincidentally awarded a life peerage in the House of Lords by transphobe and outgoing Prime Minister Rishi Sunak in July 2024.[21][22] The aforementioned Badenoch took credit, saying she "managed to get Dr Hilary Cass a peerage", and that if she were made Tory leader, would offer J. K. Rowling one, too.[23][24]

Engagement with anti-LGBT perspectives[edit]

Hilary Cass discussing criticism of her report, April 2024.

The Review consulted many non-experts, and many sources who were explicitly, self-admittedly in denial that transgender minors, the topic of the review, exist at all (32 percent of those surveyed).[11]:10 Cass herself was presented as impartial and thus especially fit to carry out the review.[25] The interim report released by the NHS in February 2022 described her as having "no prior involvement or fixed views" amidst an alleged clinical "polarisation" on trans healthcare.[26] However, according to a white paper released in August 2024 by Max Davie and Lorna Hobbs, clinicians working in child and adolescent gender care in the UK, she was "known by colleagues to oppose medical transition" at the time of her appointment.[27][28][29]

Davie and Hobbs' paper included a footnote stating that Cass had "strongly recommended" the anti-trans book Irreversible Damage: The Transgender Craze Seducing Our Daughters.[27][28][29][30][31] Screenshots of this footnote were widely shared on social media.[30] Davie updated the paper to clarify that Cass called him to "discuss [his] potential involvement" in the review "towards the end of 2020."[27][31] In Davie's recollection, Cass "expressed concerns about GiDSWikipedia practice" during this conversation, finding it "shocking" that "97% of children" prescribed puberty blockers progressed to HRT.[31][31] When Davie countered that this was likely due to "accurate triage," Cass reportedly "recommended that [he] read Irreversible Damage."[27][31] Davie claimed that he first became "aware of Dr Cass's scepticism about the GiDS model" when they collaborated on a NICEWikipedia project.[27][31] Cass dismissed the Irreversible Damage anecdote as "baseless and wholly untrue" in response to a request for comment from PinkNews.[30] In the statement, she denied having ever read the book and asserted that "the suggestion that I recommended it to anyone is fabrication," noting that she had "already been reviewing the evidence for six months" at the time of its publication.[30] Davie later removed (but did not retract) the anecdote from the paper, stating that "Dr Cass obviously saw [it] as an attack" and that he and Hobbs had set out to "robustly critique the review, not make personal attacks."[32]

Cass' statement to PinkNews raised new questions. It suggests that Cass believes her work on the Cass Review began in January 2020. It also implies that she has been aware of Irreversible Damage since its American release. The book was initially released by Regnery Publishing in June 2020.[33] It was not published in the UK until December 2020.[34] It is possible that Cass had received an Advanced Reading Copy (ARC) of the book prior to publication; ARCs are distributed to people who might want to publish a review of a book. Regnery is a right-wing imprint that mainly sacrifices trees for pundits like Ann Coulter and Dennis Prager.[28][35] Regnery also has a history of endorsing anti-science junk such as Peter Duesberg's Inventing the AIDS Virus (1996).[36] UK publisher Swift Press has cultivated a similar reputation for "standing up to groupthink."[37] The author of Irreversible Damage, Abigail Shrier, is a conservative opinion columnist.[38][39] Natalie Wynn characterised Shrier's book as "essentially to transmasculine people what The Transsexual Empire was to trans women."[40] The book centres on Lisa Littman's debunked hypothesis that peer pressure and social media are "seducing" AFAB teens into identifying as trans boys.[41][note 1]

Cass has followed Graham Linehan, LGB Alliance, and Transgender TrendWikipedia online, among other anti-trans activists and organisations.[43][44][45] In 2022 she met with Patrick Hunter of the anti-trans SPLC-designated hate group[46] SEGM to discuss a stitched-up report used to ban gender-affirming care in Florida.[47][48] Hunter also belongs to the Catholic Medical AssociationWikipedia,[47][48] an anti-abortion, anti-gay[49][50][51] organisation that opposes gender transition because, according to their interpretation, it "violates the teachings of the Church."[52]:33–34 Cass was due to speak at a cancelled 2022 teleconference for trainee child psychiatrists in the UK alongside Lisa Littman, Transgender Trend founder Stephanie Davies-Arai, Genspect[note 2] founder Stella O'Malley,Wikipedia and anti-trans columnist Helen Joyce.[54][55]

Exclusion of trans-friendly perspectives[edit]

With a transphobe specially recruited as its lead author, the Cass Review systematically excluded input from expert clinicians, trans people, and other stakeholders.[15][25][4]:8 In a paper in the International Journal of Transgender Health, Cal Horton observed that "[The Review], by design, prioritized cis professionals with no experience in trans healthcare."[25] In Horton's assessment, people consulted by Cass were chosen for their "absence of trans specific knowledge experience, including exclusion of those with lived experience of being trans."[25] The original terms of referenceWikipedia for the Review explicitly stated it "deliberately does not contain subject matter experts or people with lived experience of gender services."[25] This was later amended to a vague note on the exclusion of parties with a "significant interest in the outcome of the Review" (i.e., trans people concerned about their access to care).[25] Cat Burton, who was consulted as director of the Gender Identity Research & Education Society (GIRES), concluded that "it was obvious that the review had been written before we started."[56]

The Cass Review convened several focus groups of "former, current and potential future service users" in Spring 2023.[57] The stated aim was to "understand [the] experiences" of trans youth and to "capture their thoughts and ideas about what they need and want from services and how they would want to access them."[57] Multiple participants in these focus groups have expressed that they felt pressure to "'prove' to clinicians that they were transgender."[2] One stated that clinicians had "probed [them] so hard" for "'alternative' reasons" for their transness, including "childhood trauma, with emphasis on sexual assault."[2] This is an alternative fact propagated by anti-trans advocates,[58][59] like Genspect[60] and Parents of ROGD Kids.[61]

The full membership of the Cass Review's advisory board remains unknown.[62][63] Richard Byng and Richard Stephens of SEGM are known members.[64][65] Finnish child psychiatrist Riittakerttu Kaltiala is another.[66][67] Kaltiala established Finland's youth gender program, which has been accused of "grueling assessments, mockery, misgendering, and intrusive personal questions."[66] A 15-year-old transmasculine patient reported being grilled on his masturbatory habits and told to report back after experimenting as "homework."[66] Kaltiala decried youth transition in Finland's leading medical journal in 2011.[66][68] One of the few studies rated as "high quality" by the Cass Review was a 2020 paper by Kaltiala et al. concluded that medical transition does not "improve functioning and relieve psychiatric comorbidities" in young patients.[11][69] In 2022, Kaltiala testified in support of Florida's ban on gender-affirming care for minors,[70] and she personally introduced Cass to anti-trans Traditionalist Catholic activist Patrick Hunter.[48]

Scientific response and general criticism[edit]

Headquarters of the British Medical Association.

The Cass Review has been widely criticised by medical bodies outside TERF Island since its April 2024 release.[3] WPATH|, in a joint statement with its American counterpart USPATH, determined that the Cass Review "relies on selective and inconsistent use of evidence, and its recommendations often do not follow from the data presented in the systematic reviews."[15] PATHAWikipedia of New Zealand held that the Review makes several "harmful recommendations" and "ignores the consensus of major medical bodies around the world."[71] The American Academy of Pediatrics,Wikipedia the Endocrine Society,Wikipedia the Canadian Pediatric Society,Wikipedia and the Royal Australian and New Zealand College of PsychiatristsWikipedia have all rejected the Cass Review's findings and recommendations.[72][73][74] The Endocrine Society's statement noted that the Cass Review "does not contain any new research that would contradict" existing clinical guidelines on gender-affirming care for minors.[75]

A report produced by several researchers for Yale's Integrity Project concluded that the Cass Review "levies unsupported assertions about gender identity, gender dysphoria, standard practices, and the safety of gender-affirming medical treatments," and the systematic reviews it relies upon "have serious methodological flaws, including the omission of key findings in the extant body of literature."[11][76][77]

In July 2024, the British Medical AssociationWikipedia[note 3] broke ranks with the UK's institutional transphobia,[78][79][80][81] announcing it planned to "undertake an evaluation of the Cass Review" by the year's end.[82] The statement cited international and domestic concerns over "weaknesses in the methodologies used in the Review and problems arising from the implementation of some of the recommendations."[82] The UK's anti-trans commentariat were predictably outraged.[83][84][85]

The Cass Review drew general criticism for using AI-generated images of children throughout its final published version.[86][87] A member of Cass's "team" confirmed the use of both "real" and AI-generated "Adobe stock images" to 404 Media, explaining that, given the "sensitive and contentious" nature of the report, a "conscious" effort was made to avoid "images that could identify any individuals."[86] Abigail Anthony of National Review wrote a bizarre defense of the AI images while conceding that the cover art has "creepy fingers."[88] The Cass Review also allegedly "borrowed" the chart presented as "Figure 11" (see below) from SEGM's website without attribution.[89] The only modification was the removal of SEGM's logo from the lower right corner.[89] SEGM co-founder Zhenya Abbruzzese commented in an Undark interview that the group were "both surprised and pleased" to discover their chart in the Cass Review.[89] The Review's teal-and-orange colour scheme was seemingly inspired by SEGM's graphics.[90]

Methodological issues and unsupported claims[edit]

“”That the Review asserts that the quality of evidence on which current practice is based is inadequate and then goes on to make recommendations that are based on a lower level of evidence is striking and concerning.
—Vandermorris et al.[7]
The Integrity Project's critical notes on a graph presented in the Cass Review.[11]:16[1]:85 The chart doesn't show an "exponential" increase in GIDS referrals as claimed, but rather linear growth with levelling off, followed by a decrease and an illusory spike caused by double-counting.[11]:16 This chart was seemingly "borrowed" from SEGM without credit.[89]

A brief rundown of everything Cass got wrong[edit]

The Cass Review and the systematic reviews it drew on repeatedly violated conventional standards of evidence evaluation;[7][11]:8, 28–33 violated what can be surmised of its own standards of evidence evaluation;[11]:2 made some completely unsupported or disproven assertions;[7][11]:19–26[91]:10–11[4]:8[92] botched the use of technical terminology;[11]:8, 15–17 misrepresented/misinterpreted its own presented data;[11]:15–18, 20–21 claimed to oppose conversion therapy while uncritically and favorably citing papers "proposing methods that claim to suppress transgender identity";[11]:20–21 failed to rigorously define or explain its standards or reasoning for evidence quality;[11]:8, 28–33 failed to seriously consider other factors recommended for evaluation in the care of trans patients by e.g. a GRADE approach,Wikipedia such as risk-benefit ratios,[11]:8–10[note 4][4]:8[5] which can be important especially given the limits for achievement of "gold standard" evidence in many types of medicine.[93][11]:10–12[94]

They failed to contextualize transgender medicine within wider pediatric medicine (in such a way as to create an implicit double-standard);[11]:12–15 misrepresented the careful and considered deployment of transgender medicine as instead careless (which ran against the review's own data);[11]:18–19 oversimplified some nuanced findings;[11]:9 framed patients' advancement from social transition to medical transition as though the former caused the latter, rather than this being a demonstration that the patients are genuinely transgender;[11]:19–20 and cited papers based on surveys from anti-transgender websites while ignoring or underplaying major findings from certain papers that were based on much more rigorous methodologies,[11]:22–23[5] including even some papers that the Cass Review's own systematic reviews rated as "moderate" or "high" quality.[11]:37–38 Basically, this means the final report failed to reference certain positive evidence for trans medicine that the review's own evidence-evaluators found.[4]:9–10

Throwing out the majority of research[edit]

Hilary Cass throws out studies that don't confirm her thesis (artistic interpretation).
“”Steven Novella: If you decide after you look at the evidence what the threshold is--

Cara Santa Maria: Well, that's p-hacking. It's the equivalent of p-hacking. It's not hacking the p, it's hacking something else. It's hacking the threshold. It's post hoc determination.

Steven Novella: Or ad hoc. So rather than: 'here are the established methods that we use to evaluate whether or not the threshold of evidence has been met. And we're going to apply that established standard to this body of evidence.' They did not do that. They violated standard practice.
—The Skeptics' Guide to the Universe, Episode #995[95]:39:54–1:08:10[96]

The Cass Review's biggest methodological flaw is its nearly-wholesale dismissal of the existing body of scientific research supporting gender-affirming care.[11][97][98] Cass recruited researchers at the University of York to carry out seven systematic reviewsWikipedia (SRs) of the available scientific literature for use in the review.[11] McNamara et al. (2024) found that the York authors preregisteredWikipedia their intent to assess study quality in all seven SRs using the Mixed Methods Appraisal Tool (MMAT).[11] However, they ultimately switched to a version of the Newcastle-Ottawa Scale (NOS) with "several adaptations" introduced by themselves for half[91] of the SRs, which McNamara et al. judged to be "a divergence from standard practices designed to minimize bias in systematic reviews" and "not a minor one." This switch was not explained or acknowledged in the SRs.[11]:28–29

After the SRs conducted by the York researchers were printed in Archives of Diseases in Childhood, the journal's publisher, BMJ Group, put out a press release boasting that two of them had rejected all but one out of a pool of 50 or more studies considered.[99] Applying ROBIS, a tool recommended by CochraneWikipedia for evaluating risk of bias in systematic reviews, all of the seven systematic reviews used by the Cass Review were determined to be at a high risk of bias on every single measure (of four measures) — except for one that was low risk of bias on a single measure.[11]:31–32[91]:3–5 This was "driven by unexplained protocol deviations, ambiguous eligibility criteria, inadequate study identification, and the failure to integrate consideration of these limitations into the conclusions derived from the evidence syntheses."[91]:2

In laymen's terms, this means the Cass Review applied incomprehensible standards to its evaluation of evidence, seemingly picking-and-choosing what studies to include and exclude on an arbitrary or selective basis. This is worse than the explanation that the Review dismissed everything but double-blind randomized controlled trials (RCTs) as "low quality." That misconception has made it into media coverage and popular commentary.[97][98] RCTs have limitations. RCTs are ethically questionable or practically infeasible in certain fields, including chemotherapy, abortion medication, and gender care.[11]:12-13[98][note 5] As McNamara et al. explain, "the presence or absence of 'high-quality evidence' alone should not be used to decide whether to offer treatment" with proven benefits, since "RCTs specifically are ill-suited to studying the effects of many interventions" on trans people's well-being.[11]:12 In the case of puberty blockers, it would be impossible to successfully conduct a double-blind RCT on their efficacy in treating gender dysphoria in trans adolescents, as the placebo cohort would realise their lot upon experiencing unwanted body changes (e.g. breast development in trans boys).[11]:12-13[98][100] The overall prevalence of RCTs in pediatric medicine has declined or stagnated since the 1980s for various reasons.[101][102][103]

Weird, ridiculous, and harmful assertions[edit]

The Cass Review suggests little girls like dollies for biological reasons.
  • Toy preferences are biological: The Cass Review claims children's "toy preferences, play, and physicality" are "influenced by biological and social factors."[1]:98 It asserts that "there is evidence for [strong] prenatal and postnatal hormonal influence" in girls' apparent preference for dolls and boys' preference for trucks,[1]:100–101 but that this is somehow not also the case for gender identity[1]:101,115 despite there being evidence for that,[104] including evidence mentioned in the Cass Review itself (though it frames prenatal sex hormones in this case as "environmental influences" for some reason).[1]:115–116 It cites a 2015 study by Melissa Hines,[1]:101 who also co-authored a 2002 study claiming "sexually differentiated object preferences" in vervet monkeys.[105][106] In other words, it claimed that male vervets showed greater interest in a "car and a ball" while females preferred the "doll and [cooking] pot," a finding that assumes animals understand the purpose of human-made objects.[105][106] A later, smaller study with rhesus macaques had different findings from Hines's,[107] so it might even depend on the species of primate. (Humans are most closely related to bonobos and chimpanzees, which differ behaviorally, being matriarchal and patriarchal respectively.[108][109])
  • Porn makes kids trans?: The Cass Review suggests "more investigation into consumption of online pornography and gender dysphoria is needed."[1]:110 The only source it cites to prove the supposed need for such research is a 2024 commentary by Karin Nadrowski.[1]:110 Nadrowski argues that exposure to violent, degrading porn may induce transness in AFAB youth by increasing "shame and fear of becoming a woman," claiming that "working through" patients' sexual trauma "may correct false beliefs about gender inequality and therefore might alleviate gender dysphoria."[110] Nadrowski, a clinical psychiatrist and detransitioner, belongs to a pro-conversion therapy lobby group.[111][112] Cass stated in a May 2024 interview with NPR that "early exposure to pornography" may drive trans identification among AFABs.[111][113][114]
  • Tumblr makes kids trans?: The Cass Review stops short of endorsing the debunked concept of rapid-onset gender dysphoria (ROGD) as fact.[note 6] However, the Review makes a point of concern trolling that some of the parents it consulted were worried about online "influencers," who they believe have exerted "a substantial impact on their child's beliefs and understanding of their gender."[1]:120[note 7] It does this after spending several pages fretting over whether social media and smartphones have increased the incidence of depression, sleep disorders, and body-image issues among young people.[1]:109-111 The notion that trans identities are spread via "social contagion" has been popularised by Abigail Shrier's Irreversible Damage.[41] A colleague of Hilary Cass has alleged that she "strongly recommended" this book to him in 2020.[31]
  • Autistic people cannot know themselves: The Cass Review states that research has found "transgender and gender-diverse individuals are three to six times more likely to be autistic" than cis people.[1]:93 The cited study, Warrier et al. (2020), did indeed reach this conclusion.[115] At least one other paper supports a link between gender variance and neurodivergence.[116] The trouble lies in the Review's suggestion that issues with sensory processing and emotional expression mean autistic trans kids cannot be trusted to accurately articulate "how they are feeling about their internal sensations, their gender identity and their sexual identity."[1]:93 It uncritically repeats a 2011 study's assertion that "it can be complicated to disentangle" whether autistic trans kids' dysphoria "evolves from a general feeling of being just 'different' or a whether a true 'core' cross-gender identity exists."[1]:68[117] The Nadrowski paper more bluntly opines that the "reduced mentalization capacities" of AFAB autistics make them more vulnerable to being transed by porn.[110] The Cass Review recommends screening young NHS gender patients for "neurodevelopmental conditions, including autism spectrum disorder."[1]:148 Its claims are part of a wider ableist assault on autistic people's right to self-determination. Trans autistics have reported being delayed or blocked in accessing care by clinicians.[118] Several U.S. states restricted or banned gender-affirming care for autistics in 2023.[119]

Political context and impact[edit]

Puberty blocker ban[edit]

Health Secretary Wes Streeting.
“”The BMA has been critical of proposals to ban the prescribing of puberty blockers to children and young people with gender dysphoria, calling instead for more research to help form a solid evidence base for children’s care – not just in gender dysphoria but more widely in paediatric treatments. The Association believes clinicians, patients and families should make decisions about treatment on the best available evidence, not politicians.
—British Medical Association[82]

Puberty blockers were banned for gender dysphoria patients under 16[note 8] in the UK following the High Court's decision in Bell v TavistockWikipedia in December 2020.[121][122] The decision was overturned by the Court of Appeal in the September 2021.[123] In May 2024, shortly before the dissolution of Parliament ahead of that year's general election, Tory health secretary Victoria Atkins announced a ban on new blocker prescriptions for dysphoria patients under 18.[124][125][126][127] The surprise move exploited an emergency legal mechanism that was last invoked in 1999 to ban a poisonous herb (Aristolochia) used in traditional Chinese medicine following two deaths.[126][127][128] TransActual and the Good Law Project quickly mounted a legal challenge of Atkins' ban, arguing she hadn't shown a "serious danger to health" that justified emergency action.[129][130] A judge held that Atkins' use of emergency powers was "lawful" in late July.[131][130]

The ban would've automatically expired in September 2024 given the mechanism's emergency intent.[124][125][126] Wes StreetingWikipedia announced his plan to make the ban permanent within days of his instalment as health secretary under the newly-elected Labour government in early July.[132][133] The "temporary" ban was extended on August 22.[134][note 9] Sinn Féin implemented the ban in Northern Ireland soon after.[137][138] The "temporary" ban was extended a second time in November.[139][140] The ban was made indefinite in December in all regions of the UK.[141][142][143][144] It will be "reviewed" in 2027 following the (presumably pre-written) findings of a government-run "clinical trial" that kids seeking GAC in the UK will be funnelled into going forward.[145] As of September 2024, the Cass Review had reportedly been cited for bans in ten U.S. states and one Canadian province, despite this seeming to go beyond even the review's own published recommendations.[4]:10[146]

Blockers remain legal in the UK for the treatment of precocious pubertyWikipedia (i.e., they're fine for cis kids, but not for trans kids).[147][4]:6 In a letter to a Labour constituent, Streeting claimed that suppressing "abnormally high" hormone levels in young children has been "extensively tested" and meets "strict safety guidelines," but that "stopping the normal surge of hormones" at puberty might be bad for nebulous reasons involving "psychological and brain development."[148] A subsequent FOI request offered no answer as to whether Streeting had examined evidence or consulted experts on the safety of precocious puberty treatment before making these claims.[136] According to an academic paper in the Journal of Paediatrics and Child Health:

“”The same puberty blockers have been utilised since 1981 for treating central precocious puberty, and their use is now considered safe and effective, with no known severe long-term adverse effects. They have been licensed for central precocious puberty based on relatively short open-label studies with small groups of patients because it was impossible and unethical to perform more robust studies (i.e., randomised controlled trials). Limited evidence exists, for example, on their psychological outcomes in children with central precocious puberty. If we aspire to the same scientific rigour as Cass review then, by the transitive property, we may well consider ceasing the prescription of puberty blockers also in children with precocious puberty. …
Puberty blockers have been the standard of care for many years in different countries when applied in well-staffed certified centres with high-quality multi-professional teams, and it is very unusual in the history of medicine that a time-honoured treatment, with a good safety record, even if based on non-randomised trials and experts' opinion, is simply banned, while waiting for better evidence.
—Ludovica Barbi and Gianluca Tornese (2024)[94]

Alleged suicide coverup[edit]

Barrister Jolyon MaughamWikipedia revealed in June 2024 that multiple whistleblowers had come forward with allegations of a "huge increase" in trans youth deaths since Bell v Tavistock.[149] According to one whistleblower, there were 16 deaths of trans youth on the NHS waiting list in the three years after Bell, in contrast to only a single death in the seven years before the decision.[149] This whistleblower brought these alarming numbers to the attention of Hilary Cass and a director of the Tavistock clinic.[149] When Maugham contacted Cass about the whistleblower's claims, a representative replied pointing him to a section of the Cass Review that references "deaths of patients," but attributes suicides to those with "multiple comorbidities and/or complex backgrounds."[149] A second whistleblower alleged that Tavistock staff who planned to expose the numbers in an open letter were threatened with "disciplinary proceedings and being reported to their regulatory bodies."[149]

Maugham's revelations prompted the UK government to hastily commission an "independent review" from University of Manchester psychiatry professor Louis Appleby.[150][151][note 10] Appleby's review concluded that "the data do not support the claim" of a "large rise in suicide" among Tavistock patients.[150][151] In response, Maugham pointed out that that Appleby's review examined suicides among "current and former GIDSWikipedia patients," while the whistleblowers' claims concerned those stuck in waiting-list limbo.[151][156] Trans people seeking gender-affirming care through the NHS face years-long waitlists.[157][158] In August 2024, a 17-year-old trans man who spent four years on the GIDS waiting list without an appointment told The Guardian that trans youth were "being used for political gain and treated as an intellectual exercise, rather than as human beings."[159] Another young trans person who resorted to DIY hormone therapy after waiting five years stated that she "had to become [her] own doctor."[159] The Labour government directed kids "unsure how the ban applies to their circumstances" to a list of crisis hotlines in its August 22 announcement.[134][160] Caroline Litman filed a FOI request to learn her daughter Alice'sWikipedia widely-reported suicide was not included in Appleby's review.[161][note 11] Cass told The Times in December 2024 that it was "irresponsible for people to shroud-wave" over trans youth suicides.[162][163] This merely insults people as "irresponsible" for criticizing the government's policy that resulted in deaths.

In a 2024 survey by researcher Natacha Kennedy, parents of trans youth in the UK reported that their children experienced "sharply declining mental health, increased depression, social isolation, anxiety, stress, self-harm, attempts to avoid school and suicide ideation" following the blocker ban.[164] This is consistent with other past research into the impacts of anti-LGBT government policy on mental health.[5] Another 2024 study found a 72% increase of suicide attempts among trans and non-binary youth (TGNB) following the enactment of anti-trans legislation in several U.S. states.[165] The American study noted "the lack of an observable anticipatory effectWikipedia in the time periods leading up to the enactment of the laws," proposing that this may be due to the long, bureaucratic legislative process "diffus[sing] the effects the bill debates had on the mental health of TGNB young people."[165]

See also[edit]

External links[edit]

Notes[edit]

  1. ↑ Shrier made a number of extreme and scientifically-unsupported claims in Irreversible Damage. For example, she recommended that parents with trans sons prevent them from accessing smartphones,[42]:236 suggesting they go "to great lengths to physically move their daughters away from the schools, the peer groups, and the online communities" that supported their gender expression and identity.[42]:240–242 Shrier also compared gender transition to trauma inflicted on Jewish children during the Holocaust.[42]:113–114
  2. ↑ Genspect is also designated a hate group by the SPLC.[53]
  3. ↑ The systematic reviews produced for the Cass Review were published in Archives of Disease in Childhood. This is one of several journals belonging to the BMJ Group, publisher of the BMA's trade magazine, the British Medical Journal, which maintains editorial independence. This editorial independence has grown increasingly apparent in recent years, as the BMJ has become an outlet for fringe ideas on trans healthcare, while the BMA's policy positions have reflected scientific consensus.
  4. ↑ Quoting McNamara et al.: "The Review does not consider the harms of not offering gender-affirming medical care to a young person with gender dysphoria. The most concrete and tangible effect of not providing treatment is the development of permanent physical characteristics that do not align with a person’s gender. These include voice deepening, hair growth, breast tissue development, final height, or body habitus. The Review ignores the significant psychological pain suffered by patients with gender dysphoria, for whom these permanent physical changes are highly distressing. The Review also ignores the consequences for teens who, left untreated, must present to the world a physical appearance that is at odds with their own identity. In adulthood, these physical effects can be ameliorated to some degree with costly and invasive treatments such as surgery, hair removal, and speech therapy. These treatments do not erase the intervening years of psychological distress. The Review also selectively identifies the purported harms of treatment while failing to engage with the harms of no treatment. For example, the Review theorizes that those who have been treated with puberty-pausing medications and wish to pursue vaginoplasty may have a more challenging postoperative course. But the Review does not consider how puberty-pausing medications prevent development of unwanted breast tissue and can prevent the later need for mastectomy, which is a commonly sought surgery by transgender adults."[11]:9–10
  5. ↑ This doesn't disqualify RCTs from being used in the listed fields. When testing the effectiveness of a treatment, a placebo is generally used as a control in RCTs. However, when RCTs are done for new treatments for which withholding of treatment would be considered unethical, the control group usually consists of a currently proven treatment instead. Cancer treatment is a perfect example. RCTs are common in cancer research. However, instead of using a placebo for the control group (as withholding treatment for a disease with such a high rate of death would be unethical), the control group generally receives the same kind of treatment they would expect from your average hospital. It's still an RCT, but the C is slightly different, with no ethical qualms.
  6. ↑ It does cite a 2021 survey by Lisa Littman, author of the earlier paper proposing ROGD, in a section on respondents' stated reasons for detransitioning.
  7. ↑ The sentence initially attributes these concerns to "gender-questioning young people and their parents" before the Review tips its hand with "their child."
  8. ↑ This is the legal threshold for minors giving informed consent to medical treatments in the UK under the principle of Gillick competence.Wikipedia However, since most adolescents go through puberty well before ages 16 to 18, restricting blocker access to older teens represents a total ban for most patients in practice. Blockers are completely useless[120] to trans kids who've already been through puberty. They will not allow a trans girl to ungrow facial hair. Keira Bell, the plaintiff in Bell v Tavistock, is a political detransitioner like Chloe Cole.Wikipedia Bell was prescribed blockers at 16 and underwent top surgery at 20.
  9. ↑ This time with the added cruelty of closing two loopholes that allowed 1) importation of blockers prescribed and supplied in the European Union and 2) UK doctors to take over existing prescriptions from the EU. Jolyon Maugham has stated that these oversights suggest that Atkins' ban was drafted in "great haste."[135] Streeting chose to extend the ban on the day it was announced.[136]
  10. ↑ Professor Appleby, an expert on suicide prevention,[152] allegedly follows Rosie DuffieldWikipedia on Twitter. Duffield is a stridently anti-trans[153] Labour MP caught face-palming in response to SNP MP Kirsty Blackman mentioning a trans constituent's suicidal thoughts in a parliamentary speech.[154] Appleby also reportedly follows several "transphobic troll accounts"[155] with names such as "Unafraid Woman."
  11. ↑ Alice LitmanWikipedia, a 20-year-old trans woman from Brighton, took her life in May 2022 after spending 1,023 days on the waiting list without a first appointment. Her death prompted an inquiry in which a coroner concluded that languishing on a waiting list for nearly three years "contributed to a decline in her mental health."

References[edit]

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 "The Cass Review: Independent Review of Gender Identity Services for Children and Young People". April 2024. 
  2. ↑ 2.0 2.1 2.2 2.3 Polgreen, Lydia (August 13, 2024). "The Strange Report Fueling the War on Trans Kids". The New York Times. 
  3. ↑ 3.0 3.1 3.2 Horton, Cal; Pearce, Ruth (August 7, 2024). "The U.K.'s Cass Review Badly Fails Trans Children". Scientific American. 
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Ojeda et al. (September 2024). "Afirmación de género y evidencia en torno al suicidio: Aportes para el debate público" ["Gender affirmation and evidence surrounding suicide: Contributions to public debate"]. Sexuality Policy Watch (in Spanish).
  5. ↑ 5.0 5.1 5.2 5.3 Budge, Stephanie L.; Abreu, Roberto L.; Flinn, Ryan E.; Donahue, Kelly L.; Estevez, Rebekah; Olezeski, Christy L.; Bernacki, Jessica M.; Barr, Sebastian et al. (September 2024). "Gender Affirming Care Is Evidence Based for Transgender and Gender-Diverse Youth". Journal of Adolescent Health. doiWikipedia:10.1016/j.jadohealth.2024.09.009. ISSN 1054-139X.  Freely readable on ResearchGate.
  6. ↑ (2018). "What does the scholarly research say about the effect of gender transition on transgender well-being?". What We Know Project, Cornell University.
  7. ↑ 7.0 7.1 7.2 7.3 Vandermorris, Ashley; Metzger, Dan; Vyver, Ellie; Harrison, Megan; Harvey, Johanne (October 10, 2024). Canadian Pediatric Society. "Response to the Letter to the Editor on the Canadian Paediatric Society statement on gender-affirming care" (in en). Paediatrics & Child Health. doiWikipedia:10.1093/pch/pxae066. ISSN 1205-7088. 
  8. ↑ Tweet by Jolyon Mauham (@JolyonMaugham) Archived.
  9. ↑ Tweet by TransSafetyNow (@DadTrans). Archived.
  10. ↑ Tweet by Mark Boylan (@MarkBoylanEd). Archived.
  11. ↑ 11.00 11.01 11.02 11.03 11.04 11.05 11.06 11.07 11.08 11.09 11.10 11.11 11.12 11.13 11.14 11.15 11.16 11.17 11.18 11.19 11.20 11.21 11.22 11.23 11.24 11.25 11.26 11.27 11.28 11.29 McNamara, Meredithe; Baker, Kellan; Connelly, Kara; Janssen, Aron; Olson-Kennedy, Johanna; Pang, Ken C.; Scheim, Ayden; Turban, Jack et al. (2024). "An Evidence-Based Critique of 'The Cass Review' on Gender-affirming Care for Adolescent Gender Dysphoria". Yale's Integrity Project. 
  12. ↑ (May 17, 2024). "WPATH and USPATH Comment on the Cass Review" World Professional Association for Transgender Health.
  13. ↑ 13.0 13.1 "Update on gender identity development service for children and young people". NHS England. January 30, 2020. 
  14. ↑ 14.0 14.1 "NHS announces independent review into gender identity services for children and young people". NHS England. September 22, 2020. 
  15. ↑ 15.0 15.1 15.2 15.3 "WPATH and USPATH Comment on the Cass Review". WPATH & USPATH. May 17, 2024. 
  16. ↑ (July 11, 2024). "FOICRM (NHS ENGLAND - X24), NHS England". WhatDoTheyKnow.Wikipedia
  17. ↑ Twitter thread by @ReactiveAshley with screenshot of response to the FOI request. Archived.
  18. ↑ Heather Stewart (April 30, 2023). "Florida's rightwing governor Ron DeSantis backs Kemi Badenoch's 'war on woke'". The Guardian.
  19. ↑ Stefan Boscia (October 2, 2023). "Tory rising star Kemi Badenoch held secret talks with Rupert Murdoch". Politico.
  20. ↑ 20.0 20.1 20.2 Archived tweet by Kemi Badenoch. Transcript:

    Quoted poster (@ripx4nutmeg): "On Real Time with Bill Maher, Abigail Shrier is asked why England has taken a global lead when it comes to banning puberty blockers for children confused about their gender[sic].

    She says that there are two reasons: A centralised NHS and JK Rowling's support for gender critical feminists"

    Kemi Badenoch (@KemiBadenoch): "The third reason was having gender-critical men and women in the UK government, holding the positions that mattered most in Equalities and Health.

    You only need to look at what the SNP did in Scotland to see what would have happened had we not intervened.

    The Cass Review would **never** have been commissioned under a Labour govt. Labour did not want to know.

    We had incredible opposition from the system on everything. It was when the ministers changed that everything changed."

  21. ↑ Prinsley, Jane (July 5, 2024). "Sunak elevates Jewish doctor Hilary Cass to House of Lords in final act of premiership". The Jewish Chronicle. 
  22. ↑ Wilson, Matthew X. (July 8, 2024). "Hilary Cass Given a Seat in the House of Lords". National Review. 
  23. ↑ Amy Watson (October 17, 2024). "Kemi Badenoch: I would give JK Rowling peerage for her gender stance". The Scotsman.
  24. ↑ Christopher McKeon (October 17, 2024). "I would give JK Rowling a peerage for gender stance, says Kemi Badenoch". The Independent.
  25. ↑ 25.0 25.1 25.2 25.3 25.4 25.5 Horton, Cal (2024). "The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children". International Journal of Transgender Health. ISSN 1434-4599. 
  26. ↑ "Independent review of gender identity services for children and young people: Interim report". NHS England. February 2022. 
  27. ↑ 27.0 27.1 27.2 27.3 27.4 Davie, Max; Hobbs, Lorna (2024). Cass: the good, the bad, the critical. 
  28. ↑ 28.0 28.1 28.2 Brown, Rivkah (August 8, 2024). "The Government's Impartial Trans Healthcare Reviewer Isn't so Impartial, Colleagues Claim". Novara Media. 
  29. ↑ 29.0 29.1 Reed, Erin (August 8, 2024). "Colleagues Allege Cass Recommended Book Comparing Transition To The Holocaust". 
  30. ↑ 30.0 30.1 30.2 30.3 Hansford, Amelia (August 10, 2024). "Dr Hilary Cass denies claim that she recommended 'gender-critical' book to colleagues". PinkNews. 
  31. ↑ 31.0 31.1 31.2 31.3 31.4 31.5 31.6 Twitter thread with screenshots of the original and updated footnote
  32. ↑ Twitter thread by Max Davie (@maxdavie). Archived copies of constituent tweets: 1, 2, 3, 4, 5, 6, 7, 8.
  33. ↑ Listing for the hardback edition of Irreversible Damage on Amazon.
  34. ↑ Listing for Irreversible Damage on the Swift Press website.
  35. ↑ Lovell, Rose (April 10, 2024). "Abigail Shrier's Irreversible Damage: A Wealth of Irreversible Misinformation". Science-Based Medicine. 
  36. ↑ Horton, Richard (May 23, 1996). "Truth and Heresy About AIDS". The New York Review of Books. 
  37. ↑ Kerridge, Jack (February 15, 2022). "Meet the small publishers standing up to groupthink". The Telegraph. 
  38. ↑ Nordberg, Anna (February 27, 2024). "Who's Making the Kids Cry?". Slate. 
  39. ↑ Jones, Sarah (March 19, 2021). "Fake Feminists Fight the Equality Act". Intelligencer. 
  40. ↑ "J.K. Rowling" by ContraPoints on YouTube
  41. ↑ 41.0 41.1 Eckert, AJ (July 4, 2021). "Irreversible Damage to the Trans Community: A Critical Review of Abigail Shrier’s Irreversible Damage (Part One)". Science-Based Medicine. 
  42. ↑ 42.0 42.1 42.2 Shrier, Abigail (2020). Irreversible Damage: The Transgender Craze Seducing Our Daughters. Washington, DC: Regnery Publishing, a division of Salem Media Group. ISBN 978-1-68451-046-7. 
  43. ↑ Archived screenshots of Cass's Twitter follows by Erin Reed (@erininthemorning)
  44. ↑ Archived screenshots of Cass's Twitter follows by @TS_Erica_S
  45. ↑ Archived screenshot of Cass's Twitter follows by @shadell131
  46. ↑ "Hate Map: Idaho, Anti-LGBTQ Groups". Southern Poverty Law Center.
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  48. ↑ 48.0 48.1 48.2 Jones, Zinnia (November 29, 2023). "New trial exhibits in Doe v. Ladapo: DOH worked with Genspect leaders Stella O’Malley and Joe Burgo in July 2022; Hilary Cass met SEGM’s Patrick Hunter to discuss Florida’s anti-trans report; [...]". Gender Analysis. 
  49. ↑ Keefe, J. (2003). Homosexuality. 7 (2nd ed.). Gale. p. 67. ISBN 978-0-7876-4011-8. 
  50. ↑ Homosexuality and Hope: Questions and Answers About Same-Sex Attraction. Catholic Medical Association. )
  51. ↑ Same Sex Marriage. Catholic Medical Association. November 20, 2013.  (Non-PDF landing page).
  52. ↑ "Case 4:23-cv-00114-RH-MAF Document 180 Filed 11/06/23". United States District Court for the Northern District of Florida, Tallahassee Division
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  55. ↑ Hayward, Eleanor (March 26, 2022). "Gender event off after trans activists attack 'extreme' views". The Times. 
  56. ↑ Tweet by Cat Burton (@CatBurton_UK). Archived.
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  58. ↑ Eberstadt, Mary (July 16, 2021). "Might Trauma Affect Gender Identity?". Newsweek. 
  59. ↑ Stockbauer, Joy (March 23, 2023). "Erin Brewer Explains the Connection Between Childhood Trauma and Gender Dysphoria". The Washington Stand. 
  60. ↑ Wiley Haynes, Laura (February 15, 2023). "Gender Identity Through the Lens of Developmental Trauma". Genspect. 
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  71. ↑ "Cass Review out of step with high-quality care provided in Aotearoa". PATHA. April 11, 2024. 
  72. ↑ Reed, Erin (May 13, 2024). "Endocrine Society And American Academy Of Pediatrics Respond To Cass, Reject Bans". 
  73. ↑ Johnson, Lisa (April 15, 2024). "What Canadian doctors say about new U.K. review questioning puberty blockers for transgender youth". CBC News. 
  74. ↑ "A letter from members regarding the Cass Review and the College's response". The Royal Australian & New Zealand College of Psychiatrists. May 29, 2024. 
  75. ↑ "Statement From Endocrine Society". Endocrine Society. 
  76. ↑ Alfonseca, Kiara (July 9, 2024). "New report critiques UK transgender youth care research study". ABC News. 
  77. ↑ Jaime, Angie (July 3, 2024). "Yale Report Slams Cass Review: 'Misrepresents Data' on Transgender Youth". Teen Vogue. 
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    In the United Kingdom, anti-trans rhetoric … has also been gaining baseless and concerning credibility, at the expense of both trans people's civil liberties and women's and children's rights. … UK hate crime statistics show a sharp increase in transphobic crimes since 2015 – though only 1 in 7 victims report them to an authority. … It is also becoming increasingly difficult for individuals and organisations to publicly affirm young trans people without being subject to hostility and disproportionate questioning from wider society. The 'gender-critical' movement … has played a significant role in this process, notably since the 2018 public consultation on updating the Gender Recognition Act 2004 for England and Wales. In parallel, trans rights organisations have faced vitriolic media campaigns, in which trans women especially are vilified and misrepresented. … There is also a concerning, growing account of parents who (due to difficulties in accessing timely public health care) pursue private health care on behalf of their child, being investigated by State authorities.

  79. ↑ Fae, Jane (2022). "Facts that get in the way". British Journalism Review 33 (3): 9–11. doiWikipedia:10.1177/09564748221121455. ISSN 0956-4748. 
  80. ↑ Madeline Fitzgerald (June 29, 2022). "The Roots of Anti-Trans Feminism in the U.K.". U.S. News & World Report.

    At large, the truth is that TERFs and gender critical feminists are a small minority within U.K. feminism. They do not represent or reflect the views of U.K.-based feminists as a whole, and most U.K. based feminists reject their ideas and arguments, and consider them outdated or harmful. This does not mean they have no influence or impact, however. The trouble is that even though they are a minority, they are a vocal one, and they often have their views platformed by the media, including mainstream media. It is interesting that TERFs or gender critical feminists often say that they are being silenced by what they sometimes call the ‘trans lobby.’ Yet, even though they are indeed a small minority, their views and arguments are being platformed by many outlets just as much and sometimes more than the views of trans-affirming feminists and trans activists, and their arguments have also carried a lot of impact on policy decisions, especially in relation to the proposed GRA reforms.

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  88. ↑ Anthony, Abigail (April 18, 2024). "Cass Report AI Images: Patients Aren't Poster Children". National Review. 
  89. ↑ 89.0 89.1 89.2 89.3 Klotz, Frieda (May 20, 2024). "Pediatric Transgender Care and the Contentious Rise of SEGM". Undark. 
  90. ↑ Compare to the selection of charts featured on the main page of the SEGM websites below the self-congratulatory "SEGM in Media" section.
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  119. ↑ Rummler, Orion; Luterman, Sara (May 30, 2023). "Anti-trans laws are targeting autistic youth and those with mental health conditions". The 19th. 
  120. ↑ Puberty blockers can't be started at 18 when youth have already developed: experts by Camille Bains (Feb. 8, 2024) CTV News.
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  122. ↑ Parson, Vic (December 1, 2020). "Trans kids must understand risks of hormone therapy to receive life-saving puberty blockers, judge rules in landmark case". PinkNews. 
  123. ↑ Lawrie, Eleanor (September 17, 2021). "Ruling limiting under-16s puberty blockers overturned". PinkNews. 
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  125. ↑ 125.0 125.1 Perry, Sophie (May 30, 2024). "UK government bans private puberty blocker prescriptions for trans youth". PinkNews. 
  126. ↑ 126.0 126.1 126.2 Stone, Gemma (May 30, 2024). "Cowardly bully Victoria Atkins MP banned puberty blockers as Parliament dissolves". Trans Writes. 
  127. ↑ 127.0 127.1 Reed, Erin (May 31, 2024). "UK Secretary Uses Emergency Powers To Criminalize Possession Of Puberty Blockers". 
  128. ↑ Norton, Cherry (July 28, 1999). "Chinese herb banned after two deaths". The Independent. 
  129. ↑ "Press release: TransActual to challenge ban on puberty blockers in court". TransActual. June 6, 2024. 
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  131. ↑ "Puberty blockers ban is lawful, says High Court". BBC News. July 29, 2024. 
  132. ↑ Hansford, Amelia (July 12, 2024). "Labour's Wes Streeting 'to make trans puberty blocker ban permanent'". The Independent. 
  133. ↑ Searles, Michael (July 12, 2024). "Labour moves to ban puberty blockers permanently". The Telegraph. 
  134. ↑ 134.0 134.1 "Puberty blockers temporary ban extended". Department of Health and Social Care. August 22, 2024. 
  135. ↑ Jolyon Maughum on Twitter. Archived.
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  138. ↑ Fox, Matt (August 22, 2024). "Puberty blocker ban extended to Northern Ireland". BBC News. 
  139. ↑ "Extension to temporary ban on puberty blockers". Department of Health and Social Care. November 6, 2024. 
  140. ↑ Hurley, Lee (November 7, 2024). "UK puberty blocker ban extended". 
  141. ↑ Lavietes, Matt (December 11, 2024). "Britain bans puberty blockers for transgender minors". NBC News. 
  142. ↑ Triggle, Nick (December 11, 2024). "Puberty blockers for under-18s banned indefinitely". BBC News. 
  143. ↑ "Puberty blockers to be banned indefinitely in NI". BBC News. December 10, 2024. 
  144. ↑ "Scotland to follow UK under-18 puberty blocker ban". BBC News. December 11, 2024. 
  145. ↑ Barrie, Robert (December 12, 2024). "UK indefinitely bans puberty blockers for teenagers due to 'unacceptable risk'". Pharmaceutical Technology. 
  146. ↑ Skulski, Chelan; Romero, Diego (April 15, 2024). "Alberta committed to reviewing treatment of trans youth, Smith says in exclusive interview". CTV News. 
  147. ↑ Livingston, Eve (July 17, 2024). "Puberty blockers: what are they and why are they in the news?". The Bureau of Investigative Journalism. 
  148. ↑ Twitter post by Paul Ilett (@Paul_Ilett). Archived.
  149. ↑ 149.0 149.1 149.2 149.3 149.4 Twitter thread by Jo Maugham (@JolyonMaugham)
  150. ↑ 150.0 150.1 Appleby, Louis (July 19, 2024). "Review of suicides and gender dysphoria at the Tavistock and Portman NHS Foundation Trust: independent report". Department of Health & Social Care. 
  151. ↑ 151.0 151.1 151.2 "Puberty blocker curb has not led to suicide rise – reviews". BBC News. July 20, 2024. 
  152. ↑ Professor Louis Appleby Gov.uk.
  153. ↑ Rosie Duffield is a transphobic bigot. by Lexi Bowen (Jun 9, 2024) Medium.
  154. ↑ Gender critical MPs condemned for ‘grim’ response to mention of trans suicide in parliament by Amelia Hansford (Jun 14 2023) PinkNews.
  155. ↑ Just out of interest why does the esteemed professor & dismisser of suicide prof appleby follow transphobic troll accounts like this? by @waslottie (8:50 PM · Jul 19, 2024) Twitter (archived from 28 Nov 2024 02:44:33 UTC).
  156. ↑ Twitter thread by Jo Maugham (@JolyonMaugham) with associated images. All archived.
  157. ↑ Riedel, Samantha (August 7, 2024). "U.K. Trans Youth Wait an Average of Two Years for Gender-Affirming Care". Them. 
  158. ↑ Cowan, Michael; Cole, Hollie (March 20, 2024). "Transgender patients could face years-long wait for NHS treatment". BBC News. 
  159. ↑ 159.0 159.1 Brooks, Libby (August 15, 2024). "'I've had to become my own doctor': trans young people on life after the Cass review". The Guardian. 
  160. ↑ "Letter to patients, parents, and guardians". NHS Arden & Greater East Midlands. May 31, 2024. 
  161. ↑ Archived post by Caroline Litman on Bluesky
  162. ↑ Hayward, Eleanor (December 13, 2024). "MPs wrong to claim puberty blockers ban is discrimination, Cass says". The Times. 
  163. ↑ Hurley, Lee (December 14, 2024). "Hilary Cass accuses critics of 'shroud-waving' over trans youth harm". Trans Writes. 
  164. ↑ Kennedy, Natacha (2024). Children of Omelas: Effects of the UK Puberty Blocker Ban. 
  165. ↑ 165.0 165.1 Lee, Wilson Y.; Hobbs, J. Nicholas; Hobaica, DeChants; Price, Myeshia N.; Nath, Ronita (2024). "State-level anti-transgender laws increase past-year suicide attempts among transgender and non-binary young people in the USA". Nature Human Behaviour. doiWikipedia:10.1038/s41562-024-01979-5. ISSN 2397-3374. 
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