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Key points
- The treatment of gender distress is highly politicized, but scientific evidence is lacking.
- A new review concludes that hormone treatment may not reduce the risk of suicide in gender dysphoric youth.
- The review also finds no clear evidence that social transition in childhood has any effects on mental health.
- Blocking puberty may not induce changes in gender dysphoria or body satisfaction.
"Gender incongruence" is the term used to describe a marked and persistent incongruence between an individual’s experienced gender and their assigned gender or biological sex. "Gender dysphoria," which commonly arises after the onset of puberty, happens when gender incongruence is associated with clinically significant distress or functional impairment. Many of those who experience gender dysphoria will end up identifying as transgender (or trans, for short), an umbrella term for people whose gender identity is different from the gender they were assigned at birth.
How should children and adolescents who experience gender incongruence and gender dysphoria be treated?
Persistent emotional distress—gender-related or otherwise—is, to an important degree, a health (and healthcare) matter. Yet gender distress has in recent years become politicized, and the lives and health of gender-troubled children and adolescents have become fodder for the political and ideological culture wars. As American politics and ideology often go, this complex and nuanced issue has thus been shoved into a tired, dichotomous formula.
For the progressives, the issue is one of minority rights. Gender dysphoric children and adolescents should thus be supported in their struggle to live as they wish, free of prejudice and discrimination. Early intervention to align the children’s body and appearance with their preferred gender must be encouraged. Those who question this view are typically accused of transphobia.
For conservatives, gender dysphoria is at best a passing individual fancy or troubling societal trend to be mocked and at worst a disease to be cured. Those who want to honor and affirm children’s gender struggles are seen as hopelessly "woke" social justice warriors pushing a radical agenda.
As culture wars go, this one, too, has been generating much heat in recent years, but very little light. Thus, the clinical healthcare services provided to children and adolescents who struggle with gender dysphoria have not been based on a solid foundation of high-quality research evidence.
A move forward from this abysmal state may have just happened, in the form of The Independent Review of Gender Identity Services for Children and Young People, commissioned by NHS England in 2019, with the goal of making evidence-based recommendations on the questions relating to the provision of these services. The final report of what is known as the Cass report (for Hilary Cass, the pediatrician who chaired the review team) just dropped in April 2024. It is consequential.
For one, the report is a good example of how such tasks should be approached and executed: a thorough, detailed, evenhanded, and levelheaded examination that puts child welfare front and center and follows the available empirical evidence wherever it leads, while acknowledging—but not succumbing to—the various ideological, political, and societal forces at play.
The review examined the existing formal research as well as receiving input from “people with relevant lived experience,” organizations working with LGBTQ+ children and young people, and medical and mental health professionals who provide care and support to children and young people struggling with gender identity.
Writes Cass: “The aim of this Review is to make recommendations that ensure that children and young people who are questioning their gender identity or experiencing gender dysphoria receive a high standard of care. Care that meets their needs, is safe, holistic, and effective. “
The findings of the review are quite eye-opening.
Cass first attempts to explain the dramatic recent increase in the number of gender dysphoric cases, as well as the recent shift in the gender dysphoric population from male to female majority. She argues that the increased social acceptance of trans phenomena is not a sufficient explanation. “The exponential change in referrals over a particularly short five-year timeframe is very much faster than would be expected for normal evolution of acceptance of a minority group. This also does not adequately explain the switch from birth-registered males to birth-registered females, which is unlike trans presentations in any prior historical period.”
Cass notes that these gender dysphoria trends are immersed in the broader context of increased rates of mental health problems in children and adolescents (particularly females) in the last decade, and a corresponding increase in the number of young people “presenting with other bodily manifestations of distress; for example, eating disorders, tics and body dysmorphic disorder.” Gender identity and expression are determined by a difficult-to-disentangle mix of biological, neurological, psychological, and societal factors. Ostensible gender identity problems may thus be symptomatic of other, underlying and unresolved issues, Cass argues. Gender dysphoria, in other words, is not always about gender, just as germ phobia is not always about germs.
Cass then discusses the role and impact of social transitioning, defined here as “social changes to live as a different gender such as altering hair or clothing, name change, and/or use of different pronouns.” She notes that such transitioning is not a one-size-fits-all phenomenon. “There is a spectrum from young people who make relatively limited gender non-conforming changes in appearance to those who may have fully socially transitioned from an early age and may be living in stealth.”
She notes that a key difference between children and adolescents is that “parental attitudes and beliefs will have an impact on whether the child socially transitions. For adolescents, exploration is a normal process, and rigid binary gender stereotypes can be unhelpful.”
The debate over the benefits and harms of social transitioning is a flashpoint in the culture wars. Cass, however, found “no clear evidence that social transition in childhood has any positive or negative mental health outcomes, and relatively weak evidence for any effect in adolescence. However, those who had socially transitioned at an earlier age and/or prior to being seen in clinic were more likely to proceed to a medical pathway.”
“Although it is not possible to know from these studies whether earlier social transition was causative in this outcome, lessons from studies of children with differences in sexual development (DSD) show that a complex interplay between prenatal androgen levels, external genitalia, sex of rearing and sociocultural environment all play a part in eventual gender identity… Therefore, sex of rearing seems to have some influence on eventual gender outcome, and it is possible that social transition in childhood may change the trajectory of gender identity development for children with early gender incongruence.”
She concludes: “Avoiding premature decisions and considering partial rather than full transitioning can be a way of ensuring flexibility and keeping options open until the developmental trajectory becomes clearer.”
Cass then turns to inquire about the evidence regarding medical transitioning (a part of transition in which a transgender person undergoes medical treatments so that their physical and sex characteristics better match their gender identity).
She first addresses the common use of puberty blockers with gender dysphoric children. “The original rationale for the use of puberty blockers,” Cass notes, “was that this would buy ‘time to think’ by delaying the onset of puberty and also improve the ability to ‘pass’ in later life. Subsequently, it was suggested that they may also improve body image and psychological well-being.” The evidence, however, shows that blocking induces “no changes in gender dysphoria or body satisfaction,” she writes.
Evidence as to the effects of puberty suppression on psychological or psychosocial wellbeing, cognitive development, cardio-metabolic risk, and fertility is found to be “insufficient” and “inconsistent.” Moreover, the fact that a vast majority of young people who are started on puberty blockers proceed to masculinising/feminising hormones suggests that puberty blockers do not in fact “buy time to think” and may rather “change the trajectory of psychosexual and gender identity development.”
Cass thus proposes that “because puberty blockers only have clearly defined benefits in quite narrow circumstances, and because of the potential risks to neurocognitive development, psychosexual development, and longer-term bone health, they should only be offered under a research protocol.”
The evidence about hormone treatment is examined next. “It has been suggested that hormone treatment reduces the elevated risk of death by suicide in this population,” Cass notes, “but the evidence found did not support this conclusion.” Cass notes the lack of high-quality outcome research—short- and long-term—of hormone interventions in adolescents with gender dysphoria or incongruence.
Thus, she writes, “No conclusions can be drawn about the effect on gender dysphoria, body satisfaction, psychosocial health, cognitive development, or fertility. Uncertainty remains about the outcomes for height/growth, cardiometabolic, and bone health. There is suggestive evidence from mainly pre-post studies that hormone treatment may improve psychological health, although robust research with long-term follow-up is needed.”
Cass notes that while a diagnosis of gender dysphoria is often considered a prerequisite for hormone treatment, such diagnosis “is not reliably predictive of whether that young person will have longstanding gender incongruence in the future, or whether medical intervention will be the best option for them.” Therefore, Cass recommends “an extremely cautious clinical approach and a strong clinical rationale for providing hormones before the age of 18. This would keep options open during this important developmental window, allowing time for management of any co-occurring conditions, building of resilience, and fertility preservation, if required.”
Cass notes the overall dearth of quality long-term outcome data on both medical and non-medical interventions, which means that “young people and their families have to make decisions without an adequate picture of the potential impacts and outcomes.”
In sum, youngsters' gender concerns should not be mocked or denied. Gender curiosity and exploration are common, particularly in adolescence, and should not be unduly pathologized. At the same time, young children should not be hustled onto a path toward gender transition. However well-intentioned, the Cass review suggests that current official guidelines, such as those of The American Academy of Pediatrics, are not rooted in solid evidence.
Likewise, the popular, medicalized approach known as “gender-affirming care," which is based on the notion that children’s early declarations of identity must be accepted at face value and their transition aggressively assisted, may not be justified by the evidence. Gender dysphoria may be transitory; it may at times be a symptom of underlying stress unrelated to gender identity. Changing one’s gender affiliation and appearance are often insufficient to resolve the underlying psychological dysfunction and alleviate distress.
Yet for some youngsters, transition is a solution. “Being gender-questioning or having a trans identity means different things to different people. Among those being referred to children and young people’s gender services, some may benefit from medical intervention and some may not. The clinical approach must reflect this.”
Finally, the healthcare we provide to youngsters who are struggling with gender distress should be a means to an end of helping them, rather than a means of winning a battle in the culture wars. Focusing on gender needs to be supplanted by a focus on the person. The care we provide youngsters who struggle with gender distress needs to be based in empirical facts, not merely good intentions or ideological and political theories.
