A Cass Review for America?

A first look at the Health and Human Services Review of Pediatric Gender Medicine

Photo by Marek Studzinski on Unsplash

The Department of Health and Human Services review of evidence and best practices for the treatment of pediatric gender dysphoria was published on May 1, 2025. The Review was directed by President Trump’s Executive Order on Protecting Children From Chemical and Surgical Mutilation. The Review has been met with the predictable chorus of criticism from major medical and mental health organizations and the mainstream media.

A common criticism of the Review is that the authors are not named. The HHS press release explains that the names are being withheld in order to maintain the integrity of a post-publication peer review. Concealing the names of authors from reviewers is standard practice in academic publishing. However, it should be obvious that only authors who had already done extensive research on the issues could have produced a 400 page document in under 90 days.

An unfortunate side effect of this decision is that the authors are not available to speak to the press. As a result, press coverage has contrasted political rhetoric from the White House with political rhetoric from LGBTQ activists and medical associations.

However, in the long term the authorship will not make much difference. Hilary Cass was chosen to conduct a review of pediatric gender medicine in the United Kingdom because she had not been involved with the issue and could therefore be unbiased. Critics of the review attacked her for her lack of experience in gender medicine. By raising the issue of the identity of the authors, critics of the Review are admitting that they would prefer making personal attacks on the authors to responding to the substance of the Review.

Another criticism of the Review is that it was published after the Trump administration announced policies to restrict access to pediatric medical transition. The Review is therefore intended to justify decisions that were already made rather than to guide decision making. However, the evidence described in the Review was already available to the advisors who prepared Trump’s Executive Order in journal articles, expert reports and legal briefs or through consultation with experts. The Review fulfills a legitimate function by compiling this evidence and making it available to the public.

The fundamental objection to the Review is that it is the product of the Trump administration, which has shown a consistent disdain for scientific truth. However, anyone who claims to be on the side of scientific truth and reason is obliged to put aside ad hominem arguments and judge the Review on its merits, and these are considerable

Language and Approach

While the HHS Review has been described as an American Cass Review, it is in fact a very different, but equally valuable, document. There is a noticeable difference between the Cass Review and the HHS Review in language and approach.

Kathleen Stock describes how Cass gently attempted to inform and deprogram “those clinicians, parents and patients immersed in bubbles of identity affirmation, and cognitively isolated from any reasoning or evidence that would confound their worldview.” To that end, the language of the Cass review was moderate and still employed ideologically tinged phrases like “assigned sex.” According to Stock, pediatric gender medicine is driven by a cult-like ideology which Cass either did not understand or chose not to confront. She writes, “It is as if a modern-day medic had been tasked with reviewing the efficacy of trepanning, and then ordered to defend her findings in front of fanatical fifth-century devotees.”

The authors of the HHS Review are aware of the role of ideology in pediatric gender medicine and they challenge it throughout the Review. Chapter 2 of the HHS Review is on terminology The Review states that pediatric gender medicine has developed “a vocabulary and a mode of communicating that is scientifically ungrounded, that presupposes answers to ethical controversies, and that is in other ways misleading.”

While the Review avoids the inflammatory language found in Trump’s executive orders, it also rejects ideological euphemisms. It avoids references to the “transgender child” and uses “gender” sparingly. “Gender dysphoria” is retained because it is a defined term in the DSM. However, “gender affirming care” has been replaced with “pediatric medical transition.” Substituting “young people” for “children” obscures the fact that guidelines recommend starting puberty blockers at the onset of puberty, which can be as early as the age of 8 or 9. Terms like transgender, gender identity or even gender have no fixed meaning. The phrase “sex assigned at birth” endorses a false belief about the very nature of sex.

Rooted in Failure

In its discussion of the history of pediatric medical transition, the Review notes that while medical interventions are usually extended to children after they were proven successful in adults, the reverse was true of pediatric medical transition. A 1988 study of adult transitioners in the Netherlands, which had offered treatment since the 1970s, found that while the majority of patients claimed to be satisfied with the results of medical transition “objective measures told a different story.” Rates of suicidality remained high and the majority struggled to maintain employment and romantic relationships. The results were worse for male to female transitioners than for female to males.

The Dutch researchers hypothesized that many of the difficulties of adult transitioners were caused by their failure to “pass” as the opposite sex and if they would have better results if transition were started earlier. In 1997 they formulated the “Dutch Protocol” which consisted of puberty blockers at 12, cross-sex hormones at 16 and surgery at 18. The original protocol was very cautious. It was limited to patients who had experienced gender dysphoria since childhood, had no other mental health problems, and had family support.

Although the Dutch Protocol has been in existence for over 25 years, there has been little long term follow up. One follow up of a female to male patient after 22 years found that the patient did not regret transition but continued to suffer from depression and feelings of sexual inadequacy and had difficulty sustaining a relationship with a girlfriend. Despite the lack of supporting research, the Dutch Protocol was adopted in the United States and elsewhere and expanded with none of the caution shown by the initial researchers.

Medical Evidence

The section of the Review on the scientific evidence supporting pediatric medical transition considers the evidence examined by Cass and the additional systematic reviews published in the last year and reaches the same conclusion: gender affirming treatments are supported only by low or very low certainty evidence. It also expands on the Cass Review in significant ways.

The Cass Review did not consider gender related surgeries as these were not offered to minors by the National Health Service. However, this is not the case in the United States, so the HHS Review examined the evidence and found that there is only low certainty evidence of the effects of mastectomies on mental health, but high certainty evidence of the risk of complications such as necrosis or scarring.

Another chapter of the Review discusses evidence from basic science and physiology. Some effects of puberty blockers and cross-sex hormones can be inferred from what is known about how the human body develops during puberty. For example, it is known that puberty is a critical period for bone development, brain development and reproductive potential. None of these risks have been adequately studied.

Treatment Guidelines

The Cass Review has already found that the WPATH SOC-8 is not a high-quality clinical guideline based on a systematic review. The HHS Review goes further and examines the evidence that has emerged over the last year from WPATH internal documents that disclose conflict of interest, suppression of evidence, and political interference behind the development of SOC-8. The Review states that:

Internal documents reveal that SOC-8 authors manipulated guideline language with the explicit aim of shaping court rulings, legislative actions, and insurance coverage decisions, revealing a clear departure from the principles of unbiased, evidence-driven clinical guideline development.

Collapse of Medical Safeguarding

The authors of the Review were not able to investigate actual practices in United States gender clinics, but they were still able to uncover disturbing evidence of the collapse of medical safeguarding. While the WPATH SOC-8 is ambiguous on the requirements for a preliminary assessment before starting children and adolescents on puberty blockers or cross-sex hormones, current practice ignores even the minimal guardrails found in WPATH SOC-8. Gender clinics at major hospitals admit that they will start young patients on medical transition after a preliminary appointment of less than two hours. Whistle-blowers Jamie Reed and Tamara Pietzke have described how clinics would start patients with serious co morbid mental health conditions on puberty blockers or hormones and continued treatment even as the patient’s mental health worsened.

The Role of Medical Associations

The conclusions of the HHS Review contradict the position of every major medical and mental health organization in the United States. Chapter 12 of the Review argues that these organizations have “not properly responded to updated evidence, nor to serious ethical concerns.” The Review explains the root of the problem as follows:

However, despite their scientific orientation, MMHAs [Medical and Mental Health Associations] are not immune to institutional biases, including groupthink and the disproportionate influence of vocal, specialized subcommittees. These specialized groups may receive broad deference from the larger organization, especially when their initiatives are framed in the language of civil or human rights. Consequently, MMHAs can inadvertently become echo chambers where dissent is suppressed, confirmation biases go unchecked, and professional deference is exploited.

Policies on rare and complex conditions are usually set by specialized subcommittees. In the case of gender dysphoria in children, this has been a committee devoted to LGBTQ issues which has framed the issue as a human rights issue rather than a scientific one. Disagreement has been regarded as an attack on an oppressed minority.

The Review provides examples of how the Endocrine Society, the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, the American Academy of Pediatrics and the American Psychological Association have refused to allow any critical discussion of their policies on treatment of gender dysphoria.

Ethics

Where the HHS Review breaks significant new ground is in the section on ethics, which the Cass Review, WPATH and national guidelines have generally avoided. Discussion of medical ethics in pediatric gender medicine has focused on the issue of informed consent. There is good reason to question whether children who have just started puberty are capable of consenting to treatments that may leave them sterile and with impaired sexual function.

However, the Review points out that before the issue of informed consent arises, doctors need to determine whether the treatment should be offered in the first place. Respect for patient autonomy means that patients have a right to refuse treatment or choose between treatments where the risks and benefits are closely balanced. It does not give a patient the right to demand treatments which are not beneficial. When the low certainty evidence supporting pediatric medical transition is considered along with the known risks of harm, there is no ethical case for even offering it as an option.

The Review also addresses the question of research ethics. Health authorities in Finland and Sweden have restricted the use of both cross-sex hormones and puberty blockers in minors to research settings. The United Kingdom still permits prescriptions of cross-sex hormones to patients aged 16 and over, but has banned the use of puberty blockers except in research. The United Kingdom's National Health Service is currently seeking ethics approval for a clinical trial of puberty blockers.

The debate on research trials has focused on whether it is ethical to conduct randomized control trials of puberty blockers and cross-sex hormones. However, a more fundamental question is whether any form of clinical trial is justified. The ethical rules for medical experiments on humans require that the anticipated risks outweigh the benefits and that any risks can be adequately managed. Given what we currently know about puberty blockers and cross-sex hormones, the authors of the HHS Review argue that additional experiments on children and adolescents are not justified. Furthermore, gender clinics have failed to pursue safer alternatives such as research on psychotherapy or long-term follow up of existing patients.

Transgender activists have had to face a dilemma. On one hand, they do not want their desire for medical transition “pathologized” through a mental health diagnosis. However, they also want their medical costs covered by insurance and this requires some form of diagnosis. Activists have tried to resolve this dilemma through changes to the definitions in the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases. These changes have moved the goals of hormonal and surgical treatment away from resolving psychological distress to satisfaction of adolescent’s embodiment goals. The authors of the Review describe this as a shift from clinical error to clinical recklessness.

Using the Review

There is, of course, much more in the Review which is not discussed here. For someone who is new to the debate on pediatric gender medicine, the Review provides a comprehensive introduction which is detailed enough for a medical professional but still accessible to a layperson. For those who are already familiar with the issues, the Review is a ready reference to the most current research.

It would be naïve to expect that the thorough research and careful arguments in the Review will cause any of the current supporters of pediatric gender medicine to change their minds. However, that was never its intention. The real value of the Review is as a resource for reaching the leadership in the medical and mental health community who, up to now, have been willing to leave this matter in the hands of a small group of activists.

The excuse for deferring to specialized subcommittees on the issue of childhood gender dysphoria is that it is very rare. However, the Review points out that a recent study of private insurance data published in Jama Pediatrics found that around 1 in 1000 American 17-year olds in the insurers’ records received a prescription for cross-sex hormones between 2018 and 2022. This is comparable to the prevalence of Type 2 diabetes, which has been described as an epidemic. If the leadership of the medical and mental health professions want to get politicians out of medicine, they need to stand up to the political activists within their organizations and promote decision making informed by science, ethics and open debate.