The Cass Review Sets a Dangerous Precedent for Ideology Overruling Medical Judgement
A doctor writes that Cass distorts the normal process for treating rare diseases with off-label medications.
Opinion, by Emry Cohen, MD
On July 29th, a High Court judge in the UK upheld the decision of former Health secretary Victoria Atkins to ban puberty blockers for transgender children (and only transgender children) following the ‘findings’ of the Cass Review. This decision has sparked outrage among the gender affirming medical community, with the British Medical Association speaking out against the report and the court’s decision. Across the Atlantic, a Yale Law Review called out the Cass Review for “repeatedly [misusing] data and [violating] its own evidentiary standards by resting many conclusions on speculation”. While it has been encouraging to see those involved in gender affirming care start speaking out on the harm being done to British trans children, the implications of the Cass Review still cast a large shadow over the medical community and how we treat our patients.
Before we discuss this report in detail, let’s pull back a moment and discuss who the major players are in the medical system, how we arrive at treatment plans in general, and what role does research play in facilitating the treatment of patients.
In an ideal world, doctors would diagnose a problem, develop a treatment in conjunction with pharmaceutical companies, perform rigorous testing of the treatment, and then implement the best and safest treatments for their patients. If only.
One of the biggest obstacles standing in the way of this model is the fact that pharmaceutical companies are not driven by patient outcomes but rather by profits. Because of this, the US Government, for instance, has had to step in on behalf of patients to develop the Orphan Drug Act as a way to incentivise pharmaceutical companies to produce drugs for rare conditions (as defined by affecting less than 200,000 people). As the National Organization for Rare Disorders (NORD) reported in 2023, “There are more than 7,000 known rare diseases with fewer than 10 percent having a treatment and even fewer have cures...Half of rare disease patients are children, whose hope for a future resides in the continued tenacity and unwavering commitment of the rare disease movement.” A recent article in STAT described the devastating impact on families when pharmaceutical giant Rosse suddenly canceled a clinical trial, citing the profit motive.
But doctors are still responsible for helping their patients. We, as a medical community, cannot simply say, “Sorry, there’s no treatment” and turn suffering patients away. So doctors are often asked to use their knowledge of anatomy, physiology, and pharmacology to come up with treatments using already established medications. This is typically known as “off-label use”, meaning that doctors are using the drugs for conditions that they weren’t federally approved for. This is not uncommon. A 2023 study found that, “Off-label use of drugs is common, constituting up to one-third of all prescriptions for common drugs in the United States overall, and up to 97% of drug use in some patient populations.”
From these cases where old drugs are used in novel ways, clinicians can start building a knowledge base for future studies. This building of studies on top of each other can be illustrated by using a pyramid (below is the same version of this pyramid that Dr. Cass used in her report):
However, while Dr. Cass stresses the importance of using systematic reviews, meta-analyses, and randomized controlled trials, she seems to ignore the base of the pyramid and the steps it took to get to the top. This model is shaped like a pyramid for a reason; yes there is the tip of the pyramid, but you cannot get there without first building a base. Supporting bans on a promising off-label treatment because the evidence quality is still low is like a pharoah demanding the top of his pyramid be built with no foundation.
Now, this is not to say that Randomized Control Trials (RCTs) do not play a role in clinical medicine but to hold up patient care for these trials is not the answer. As we are seeing in real time, whistleblowers have been coming forward to suggest that the number of suicides among transgender youth on the NHS waiting list has increased in the years since the Bell v Tavistock case made puberty blockers inaccessible to trans youth in the UK.
There was hope in the UK that the new Labour government would end the insanity, but such hopes were dashed when the new health secretary, Wes Streeting, upheld the Tories’ ban on puberty blockers.
When asked why puberty blockers would only be restricted for trans children, Wes stated, “This is because the puberty blockers are suppressing hormone levels that are abnormally high for the age of the child. This is different to stopping the normal surge of hormones that occur in puberty. This affects children’s psychological and brain development”.
This is, frankly, nonsense from a medical perspective. The medicine cannot discriminate between ‘normal surge’ and ‘abnormally high’ hormone levels, it cannot tell if the patient is 7 or 12, and it will have the same side-effect profile in both the transgender and precocious puberty populations. The only difference is that the mainstream has apparently decided that increasing a child’s height is worth the risks, but protecting trans youth isn’t.
Lastly, it is important to stress why we are even prescribing puberty blockers in the first place. The medical community as a whole and Dr. Cass’ team of cis people have expressed concern over trans children regretting their transition and their inability to have children. We are not giving puberty blockers to improve inward and outward sense of self, nor do they have any effect on improving mental health and suicidality, aside from giving the trans children temporary relief from the uncontrollable change of natural puberty. This makes puberty blockers more of a stepping-stone than anything actually therapeutic. A stepping-stone that, if removed, will force trans children to undergo a puberty they never wanted in the first place. If you’re cisgender and reading this, think about if we tried to force hormones on you. How would that make you feel? Because this is the same thing being put on these children.
When looking at it through this lens, it paints a clearer image that many cis leaders in the medical community, especially Dr. Cass, are just uncomfortable with trans people and the autonomy of the trans community to pursue transition. (I’m sure there is a word for this specific kind of fear or phobia…). By continuing to restrict care, overruling doctors’ ability to make medical decisions, and altering how the medical community synthesizes evidence, the only result will be harm to trans people and worsen the mental health crisis amongst the trans community.
But that’s not all. Accepting flawed reports such as this one normalizes allowing the government to remove life saving medication from the marketplace based on ideological rather than medical concerns. Puberty Blockers are just the start. What comes next could be estrogen, mifepristone, or even the oral contraceptive pill. Trans medicine is the canary in the coal mine for everyone’s ability to make medical choices free of ideological meddling. We ignore this warning at our peril.
Emry Cohen is a trans physician with a passion for transgender healthcare and patient advocacy. As a prior collegiate athlete and Navy veteran, they offer a unique perspective on many of the challenges facing the trans community.