The Global Response to the Cass Review: June 2024 Update

A guide to the international debate on youth medical transition, where medical authorities in the United States depart from a growing international consensus.

The United States is quickly becoming a global outlier due to the reluctance of its major medical organizations to align their treatment guidelines for gender dysphoric youth with the best available evidence.

This article was originally published on May 13, 2024, but has been updated to reflect recent developments. In addition to the latest updates, this article provides a comprehensive overview of changes from countries with pediatric gender clinic services over the past several years.

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The world is reacting to the U.K.'s Cass Review and associated systematic evidence reviews, which found "remarkably weak" evidence supporting medical interventions for gender transition in minors. Released on April 9, 2024, the final report from the national gender clinic service for those under 18 — following four years of meta-analyses of the available literature — dealt a major blow to the gender-affirming model of care and marked its termination in England.

England’s National Health Service, which commissioned the report, expressed gratitude to Dr. Hilary Cass and committed to implementing her recommendations. These advocate for primarily relying on psychotherapy to address gender-related distress in minors and discontinuing the use of puberty blockers. The NHS predicted the landmark review would have "major international importance and significance" — a prediction that has proven correct.

In the last several years, we saw the U.K., Sweden, Finland, and Denmark adopt a more cautious approach by placing restrictions on medical interventions for treating gender dysphoria in minors. Norway has also signaled intentions to follow a similar path.

Now, the Cass review has mobilized other countries to begin reevaluating their practices — with the exception of the United States. The following is an overview of recent updates in the two months since the Cass review was published, followed by a comprehensive review of all updates in recent years from countries that offer pediatric gender clinic services.

What’s New

Germany and Switzerland

On June 6, 2024, two major medical societies, DGPNN in Germany and SGKJPP in Switzerland, announced their rejection of the new "gender-affirming" German guidelines for minors. The primary issues are the guidelines' failure to review evidence post-2020 and their reliance on WPATH. DGPPN, Germany's largest mental health association, stated they would reject the current draft if finalized, supporting medical interventions only for a limited number of cases within clinical studies.

On May 22, 2024, fifteen chairs and senior members of Germany's Child and Adolescent Psychiatry Association published a rebuttal to the draft of German guidelines for gender-dysphoric youth.

In early May 2024, the German Medical Assembly, a pivotal body representing medical professionals across the country, passed a resolution that calls for the restriction of puberty blockers, cross-sex hormones, and surgeries for gender dysphoric youth to strictly controlled research settings. Another resolution passed that stated minors should not be permitted to "self-identify" into a chosen sex without first undergoing a specialist child and adolescent psychiatric evaluation and consultation.

Chile

On June 7, 2024, Chile's Health Minister ordered the public health system to stop providing puberty blockers or cross-sex hormones to new patients, according to a report by

Gender Clinic News

. Existing patients will continue treatment on a case-by-case basis. An official policy statement reflecting the change is expected soon. This decision follows a similar restriction by the private UC Christus health network on June 5, both acknowledging the weak scientific evidence for pediatric gender medicine and the need to review England’s Cass report.

The Netherlands

On June 6, 2024, the Dutch Minister of Health addressed the Dutch Parliament, acknowledging the Cass Report and formally requesting the Dutch Health Council to advise on the use of the Dutch protocol for transgender care. The Health Council is expected to begin the advisory process this year. The Minister's information package to Parliament also included brief responses from the three gender clinics in Amsterdam, Groningen, and Nijmegen.

France

On May 28, 2024, the French Senate voted to pass a draft law to restrict puberty blockers and prohibit cross-sex hormones and transgender surgery for minors. Under the bill, a minor seeking puberty blockers must visit a specialized multidisciplinary center, undergo an assessment for contraindications and capacity to consent, and wait at least two years from the first appointment at the center before starting treatment.

United Kingdom

On May 29, 2024, the United Kingdom government passed legislation to ban the private practice prescription of puberty blockers, including those sourced from abroad. Previously, in March 2024, the National Health Service (NHS) had restricted puberty blockers to trials. This new legislation means that no minor in England, Scotland, or Wales can receive a prescription for puberty blockers unless participating in strictly controlled research settings. The emergency measures will last for three months, requiring further action to become permanent.

Scotland and Wales

In April 2024, in response to the Cass Review, Wales and Scotland have joined England in halting new prescriptions of puberty blockers for minors under 18 diagnosed with gender dysphoria. Additionally, in Scotland, cross-sex hormones will not be available to those under 18.

Belgium

On April 9, 2024, leading physicians in Belgium published a report advocating for significant reforms in the treatment protocols for gender dysphoria in children and adolescents. The report emphasized the need to follow the precedents set by Sweden and Finland, where hormones are regarded as a last resort. Their findings and recommendations were published in a prestigious medical journal associated with Dutch-speaking medical faculties in Belgium and their alumni associations.

International Bodies

International bodies such as the United Nations (UN) have also responded to the Cass Review. On April 24, 2024, the United Nations Special Rapporteur on violence against women and girls, Reem Alsalem, issued a statement on the UN’s website declaring that the Review’s recommendations are essential for protecting children, especially girls, from harm.

In addition, the European Society of Child and Adolescent Psychiatry (ESCAP), a prominent umbrella association of 36 Child and Adolescent Psychiatry societies worldwide, issued a policy statement on April 27, 2024. They urged healthcare providers to "not to promote experimental and unnecessarily invasive treatments with unproven psycho-social effects and, therefore, to adhere to the ‘primum-nil-nocere’ (first, do no harm) principle."

These responses stand in stark contrast to that of World Professional Association for Transgender Health (WPATH), a body-modification advocacy organization. WPATH emailed a statement to its subscribers in response to the Cass Review, vehemently rejecting its findings and adhering to its ideological beliefs. WPATH criticized the Cass Report as “harmful” and "rooted in a false premise" that suggests distressed children can be helped without "medical pathways.”

United States

In response to the Cass Review, the American Academy of Pediatrics (AAP) and the Endocrine Society (ES) provided statements to WBUR on May 8, 2024, doubling down on their endorsement of the gender-affirming model of care and medical interventions for minors. Both blamed “politics” for spreading “misinformation.” Meanwhile, prominent gender clinicians have expressed to WBUR that they are “perplexed and concerned” by these organizations’ statements, given the Cass Review’s findings.

AAP President Dr. Ben Hoffman responded to Dr. Cass's statement in a New York Times article on May 13, 2024, where Dr. Cass claimed that American medical organizations are misleading the public by overstating the strength of evidence supporting youth transition. Dr. Hoffman stated, "Any suggestion that the American Academy of Pediatrics is misleading families is false."

WPATH, AAP, and ES continue to mislead the public by claiming that the gender-affirming model of care adheres to the principles of evidence-based medicine (EBM), despite clear evidence to the contrary. Their recommendations for medical interventions are not grounded in robust evidence but rather rely on "circular referencing" of each other’s guidelines, effectively creating a citation cartel.

On June 5, 2024, the American College of Pediatricians (ACPeds) launched a new initiative called the Doctors Protecting Children Declaration, urging U.S. medical organizations to stop promoting medical interventions for children with gender dysphoria and instead recommend comprehensive evaluations and therapies for underlying psychological conditions and neurodiversity.

Comprehensive Overview of the International Debate On Youth Transition by Country

In recent years, there has been an ongoing debate about the best approach for treating gender-distressed youth, addressing the global increase in young people, primarily adolescent females, seeking services from gender clinics. Countries with pediatric gender clinic services have shown varied responses, ranging from highly medicalized treatment pathways to approaches that prioritize psychotherapy.

Nations such as the UK, Sweden, Finland, and Denmark have taken unified steps to heavily restrict medical transitions for minors, aligning their guidance with the results of systematic evidence reviews, with Norway similarly indicating moves in this direction. Elsewhere, medical and health authorities remain divided on best practices, although there are signs of some reevaluating their positions on the medical transition of minors. This guide will highlight significant updates and changes observed in these practices over recent years.

The Netherlands