Fact Checking Critics of the Cass Review

A flood of false claims about England’s Cass Review has coursed across social media and the press and among activists and academics. If only they had actually read it.

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This article was originally published on Benjamin Ryan’s Substack.

About the Author

Benjamin Ryan

is an independent journalist, specializing in science and health care coverage. He has contributed to The New York Times, The Guardian, NBC News and The New York Sun. Ryan has also written for the Washington Post, The Atlantic, The Nation, Thomson Reuters Foundation, New York, The Marshall Project, PBS, The Village Voice, The New York Observer, the New York Post, Money, Men's Journal, City & State, Quartz, Out and The Advocate. 

Learn more about Ryan’s work on his website, and follow him on X @benryanwriter.

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On April 9, the long-awaited Cass Review detonated in England. Its effects have been felt around a world torn asunder by the politicized subject of gender. The 388-page report, which was supported in part by six independent systematic literature reviews that were published by the BMJ, scrutinized the science behind pediatric gender-transition treatment.

Cass found that the practice of prescribing puberty blockers and cross-sex hormones to minors was based on “remarkably weak evidence.”

In the report’s fallout, furious clouds of misinformation have formed, fueled by people who doubtfully have read much—or any—of the report or the BMJ papers. These people have falsely claimed that Cass only accepted randomized controlled trials, or RCTs, as evidence to consider in her massive report.

I write this article as the same lone warrior who battled monkeypox misinformation (and made a typo doing it) two years ago. I write in hopes of setting the record straight on a few key points. I write as a dismayed middle-aged man who remains, at his heart, the same frustrated child who always did the reading before class, and who was forced to sit and listen to those who hadn’t done their homework dominate the discussion.

The following is a distillation of various fact-checking tweet threads I’ve published regarding the Cass Review. Individual tweets are hyperlinked throughout the text if you would care to refer to, comment upon, or retweet them.

To learn about the specifics of the Cass Review, you can check out my coverage in The New York Sun, my tweet thread about that article, and my thread about the report.

This particular article will be devoted to the dying art of fact checking.

Here’s What’s At Stake

Many advocates of gender-distressed young people are furious that systematic literature reviews, they argue, set the evidentiary bar too high. They say these reviews forbid the acceptance of lots of promising findings from perfectly good studies on pediatric gender-transition treatment.

Others say those evidence-based-medicine standards of assessing the strength versus weaknesses of research are vital to prevent research that makes erroneous claims from impacting health policy and sending it astray.

They note that the stakes are high when it comes to pediatric gender-transition treatment, in particular considering the drugs in question may impact fertility and sexual function. Fertility, they say, is a human right. And since children cannot consent to their own care, the adults responsible for their care—parents or guardians and doctors—need to be especially sure before they consent to or provide drugs that could take a child’s fertility.

Here’s the question: Where does the pediatric gender-dysphoria care field go from here, now that Cass has said the evidence is weak and uncertain (as have multiple previous systematic literature reviews)? Should it accept the claim of GLAAD, the LGBTQ media watchdog group, that the “science is settled,” and that puberty blockers and cross-sex hormones should be widely provided to gender-distressed children?

Or should the pediatric gender-medicine field follow the lead of Cass and England, and of Scandinavian nations, re-classifying pediatric gender-transition treatment as experimental and, accordingly, restricting it to clinical trials only Then, if the results of those clinical trials are favorable, it is possible that those European nations will change course again and broaden access to puberty blockers and cross-sex hormones for minors? Perhaps then they would be satisfied that the evidence is strong enough?

Here in the US, we have a split-screen system, quite unlike the European nations:

• 23 red states have passed bans of pediatric access to puberty blockers and cross-sex hormones for gender distress. Many are tied up in the courts. The Supreme Court will almost surely settle the matter.

• Blue states support liberal access to such medications.

The major US medical societies, in particular the American Academy of Pediatrics and the Endocrine Society, along with the medical/activist group WPATH, all support liberal access to pediatric gender-transition treatment. This is in stark contrast to Cass/England’s approach.

So wide is the gulf between Cass and WPATH that after Cass supported forbidding puberty blockers and cross-sex hormones to minors, WPATH said that the majority of gender-dysphoric adolescents would fare better on such medications than with the holistic mental-health care Cass advises and that is now policy in England.

At stake here is the question of how scientific research is translated into health policy.

• Who gets to decide, and what methods do they use to assess the research?

• What is the best way to do this, to ensure that the best possible care is provided to vulnerable young people?

The most important question is this: How can patients, families and healthcare and mental-health providers be provided the most robust and informative information possible to guide their shared decision-making as they weigh the risks versus benefits of treatment?

Cass says that WPATH’s guidelines are weak. WPATH countered in their recent statement by asserting that they, WPATH, are the subject-matter experts on pediatric gender-transition treatment, not Cass. The American Academy of Pediatrics, meanwhile, has been sued, along with the author of its 2018 policy statement backing pediatric gender-transition treatment and the overall “affirmative” model of care, in a medical-malpractice suit that I covered for The New York Sun.

False Claims Have Widely Circulated That Cass Rejected all Non-Randomized Controlled Trials

Cass does indeed state that randomized-controlled trials are the gold-standard of scientific studies. Meanwhile, many claim that an RCT for gender-transition treatment would be unethical to conduct among children, because the preponderance of evidence indicates the treatment is safe and effective. (Others vigorously dispute that such a trial would be unethical and that such evidence is trustworthy—hence, they say, the need for an RCT.) Furthermore, it is not possible to blind such a study, because the effects of the drugs (i.e., suppressed puberty or cross-sex puberty) are too obvious.

However, neither of the two systematic literature reviews on which Cass was partially based—one about puberty blockers, the other about cross-sex hormones to treat gender distress in minors—place RCTs as the bar that the 103 studies they assessed needed to meet. Rather, they used a validated assessment tool known as the Newcastle-Ottowa scale, which is designed to assess the strength of observational studies.

This is how one of the papers described the scale:

Neither of the studies deemed high quality by the reviews were RCTs.

And so, the widespread claims that the Cass Review set an impossibly high bar to reach by demanding only RCTs, discarding 101 out of 103 studies of pediatric gender-transition treatment, are: FALSE

Let’s examine how Dr. Hilary Cass and her team did factor in the systematic literature reviews about puberty blockers and cross-sex hormones.

One systematic literature review examined puberty-blockers for gender distressed kids. It examined 50 studies, and included in its synthesis one high-quality study and 25 moderate-quality studies. It did not simply ignore the 24 low-quality studies.

The other systematic lit review examined cross-sex hormone use for gender distress in minors. It examined 53 studies, and included in its synthesis one high-quality study and 33 moderate-quality studies. But it did not simply ignore the 19 low-quality ones.

What about the Cass Review? How did it make use of the two systematic lit reviews? The claim that Cass simply discarded the 101 moderate/low-quality studies and only looked at the two high-quality studies is: FALSE

She folded the analyses of the 103 studies into her report.

Let’s zoom in to the 388-page Cass review. To see where she first folds in the findings of the systematic literature review of cross-sex hormones, go to page 183. Here is how she introduces that paper:

Cass includes in her report the following chart from the lit-review paper on cross-sex hormones, which breaks down all the studies it analyzed and what outcomes they addressed. Cass is pointing out key areas where more research is needed, in particular about fertility outcomes. So you can see that this report is about way more than just the narrow question of treatment efficacy. It’s about the whole field of pediatric gender medicine and the research apparatus behind it.

On page 184 of the Cass Review, she goes into considerable detail about the findings of the systematic literature review about cross-sex hormones. She does not solely focus on the one high-quality study, although she does certainly highlight it. She refers to all 53 studies.

The review discusses the findings of the systematic literature review on cross-sex hormones for minors amid discussions of lots of other individual papers about pediatric gender-transition treatment. The review also folds in the findings from the systematic literature review about puberty blockers for gender distressed minors (p. 175).

Cass includes the following chart from the review paper on puberty blockers for gender-distressed kids, which breaks down the outcomes examined by the 50 studies. It points to areas where much more research is needed, especially about…fertility.

From page 176 to 177, Cass has lots to say about the specifics of the puberty blocker systematic literature review. She does not restrict her discussion to the one high-quality study included in the review.

The Review includes 15 pages of footnotes of studies, guidelines, and other sources on which the report is based. The report is not solely based on two studies.

In sum, those who say Cass and the lit reviewers simply discarded 101 studies are incorrect. However, because the quality of the study findings was overwhelmingly weak, Cass was indeed very limited in which studies she could rely on in assessing safety and efficacy in particular.

Cass sums up the matter as follows in her introduction:

Who Has Made False Claims That The Cass Report Rejected All Non-RCTs?

The Canadian Broadcasting Corporation published an article quoting doctors repeating, and failing to challenge, the false claim that the Cass Review disregarded any studies about pediatric gender-transition treatment that were not randomized controlled trials. The article made various other false or misleading claims, such as that puberty blockers are at least believed to be safe and reversible. Sallie Baxendale’s recent scholarship, along with Cass’s findings, have shown how neither of those claims are known to be true. Much more research is needed.

Continuing a running theme in our culture of late, hundreds of academics have signed a letter protesting the Cass Review that strongly suggests they have not read the review or the systematic literature reviews on which it is partly based. Their letter falsely claims the Cass Review “does not include a proper systematic literature review since it disregards most research evidence because it fails to reach the impossibly high bar of a double-blind trial.”

The letter was spearheaded by transfeminist sociologist Natacha Kennedy and her colleagues at the Feminist Gender Equality Network.

Numerous accounts on X (formerly Twitter) broadcast the false claim that the Cass Review and two of the systematic literature reviews on which it was based simply discarded 101 of 103 studies on pediatric gender-transition treatment. This includes the British singer Billy Bragg, Dr. David Gorski (who also falsely claimed that Cass referred to so-called rapid-onset gender dysphoria in her report) and activist Substacker Erin Reed:

In her most recent Substack published April 18, Erin Reed continued to further the falsehood that Cass “disregarded” all but high-quality studies. She also made false or misleading claims about: the subjectivity of the systematic literature review’s scoring system; the ongoing debate over whether gender dysphoria is influenced by social contagion; the false notion that the Cass Review aligned itself with an anti-trans propagandist; and the detransition rate.

In a lengthy YouTube video, British political activist and pundit Owen Jones (who once interviewed me about monkeypox when I was very swollen and bald from chemo) repeatedly made the false assertion that the Cass Review excluded all non-RCTs.

Jones also falsely claimed that none of England’s pediatric-gender-clinic patients were sped through the assessment process. The Cass Review shows that at a minimum, hundreds of children were referred to endocrinology after no more than four assessment appointments.

Jones also repeatedly said that the rate of detransitioning—people who after taking cross-sex hormones stop the medications and revert to identifying as their biological sex—is about 1 percent, saying that long-term studies show this. This despite the fact that Cass said in her report that because of a lack of long-term follow-up, the detransition rate is unknown.

How Did All This Misinformation Get Started?

From what I can estimate, the first person to have pushed the false claim that Cass simply discarded 98 percent of the available studies about pediatric gender-transition treatment was trans activist and attorney Alejandra Caraballo.

The key problem is that Caraballo cited the wrong systematic literature reviews in a viral tweet about the Cass Review.

Five hours before the Cass Review was published on April 9, Caraballo tweeted a screenshot of what appeared to be the new systematic literature reviews that would be published alongside the Cass report. But these screenshots were actually from the so-called NICE reviews—from 2020.

The tweet quickly racked up hundreds of thousands of views and has 850K to date.

The NICE reviews of the pediatric use of puberty blockers and cross-sex hormones for gender distress relied on the GRADE system, which with rare exceptions only gives high-quality ratings to randomized controlled trials.

Caraballo apparently did not yet have a copy of the final Cass Review report at this time. If Caraballo had waited until the new systematic literature reviews on which it was partly based, Caraballo would have seen that they did not throw out all but RCTs.

I am quite certain Caraballo did not have access to the Cass Review’s final report before the embargo lifted (at 7:01pm ET April 9), because shortly before the embargo was set to lift, Caraballo tweeted what was quite apparently thought to be the Cass report. But the link was to the review papers, not the report. As you can see, I told Caraballo on April 9 that the tweet had not, as claimed, linked to the Cass Review:

And of course amid all this, uber-popular debunking podcaster Michael Hobbes, who once hosted a show called You’re Wrong About, weighed in.

This reminds me of the time Hobbes hate tweeted about the feature in The Atlantic that I wrote about carpal tunnel syndrome and spent half the summer researching. He dismissed it with a wave of the hand. It was obvious he had not read it.

I will leave you, dear reader, with one small, yet mighty request:

PLEASE DO THE READING.

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