By Chan Kulatunga-Moruzi
January 24, 2025
Primum non nocere – do no harm – is a foundational principle of modern medicine. And yet, in Canada, advocates of “gender-affirming care” seem to have forgotten this guiding value. As other countries rein in invasive gender treatments for children and youth amid growing scientific evidence of the uncertain benefits and harms of these treatments, Canada remains a laggard.
On April 10, 2024, the much-awaited Cass Review was published in the United Kingdom (Cass 2024a). The Review, commissioned by England’s National Health Services (NHS) in response to the dramatic rise of youth referrals to UK’s Gender Identity Development Services. The report, written by Dr. Hilary Cass, was the culmination of nearly four years of work – informed by more than 1,000 interviews with stakeholders, 18 focus groups (Cass 2024b) and nine commissioned studies (BMJ Undated), including systematic reviews of the evidence, a review of 23 guidelines for the treatment of gender-distressed youth, and an international survey of the current provision of gender services for youth.
Cass’s recommendations are starkly at odds with Canada’s current genderaffirming care model, a clinical approach that respects an individual’s gender identity, their internal sense of being male or female (or some other gender), and their right to socially and medically transition. This model assumes that the concept of gender identity is valid and that thus, a patient’s self-declared gender identity is real. The role of the doctor, therefore, is not to help the patient examine the source(s) of their gender distress, but to provide medical, psychological, and social support to help individuals transition so they may present as their self-identified gender. This approach is used for children, adolescents, and adults.
While some of the most developed and medically advanced countries have signalled strong caution in recently published clinical guidelines and have backed away from endorsing gender-affirming care for youth, Canada remains an outlier. Canadian paediatricians are still basing the care of gender-dysphoric youth on the Canadian Paediatric Society’s position statement (Vandermorris and Metzger 2023). The often ideological and polarized debate on youth gender medicine has led to biased and partisan reporting in Canadian media, and an intransigence on the part of medical organizations to critically assess the evidence. Unfortunately, none of this serves the interests of an already vulnerable group. In order to “do no harm,” medical professionals must follow a cogent approach based on evidence.
Upon the release of the Cass Review NHS England immediately issued a new service specification (NHS England 2024a) ending the routine use of puberty blockers for gender dysphoria. The Ministry of Health introduced regulations that prohibits private and public prescribers from selling or supplying puberty blockers to new patients under 18. (Puberty blockers may still be prescribed for carefully assessed patients over the age of 16 to be used in combination with cross-sex hormones). The Department of Education in England also tabled a consultation, Provisions to Support Gender-Questioning Children in Schools (Long 2024), in light of the findings regarding social transition.
Summary of findings and recommendations of the Cass Review
The Cass Review’s findings with respect to the evidence for gender-affirming medical treatments were consistent with Finland and Sweden’s guidelines, the only two guidelines (of the 23 reviewed) that followed a robust and transparent development process and based treatment recommendations on findings of systematic reviews. Given the “remarkably low evidentiary base” and a costbenefit analysis of the known benefits and risks, and potential long-term risks, the review recommended a sharp departure from the gender-affirming care model.
Among its other findings and recommendations:
• Except for the Finnish and Swedish clinical guidelines, the remainder of the 23 guidelines for the treatment of gender distress in young people did not use a transparent and robust guideline development process. Further, there was circular referencing so that guidelines were not independent.
• The polarization of transgender issues adversely affected the way clinicians practiced, resulting in “diagnostic overshadowing” – where a patient’s mental health difficulties are viewed through the lens of conflict between biological sex and gender identity, rather than exploring other factors. This impeded the ability of clinicians to provide holistic comprehensive care.
• The evidence supporting all aspects of gender-affirming care for youth is “remarkably low” and there are no data on long-term outcomes.
• Social transition, the adoption of a new name, pronouns, clothing, hair, and make-up to present consistent with one’s internal sense of gender, often thought to be benign, is, in fact, an active psychological intervention that may change a young person’s identity development, including their gender-development trajectory. Social transition should be initiated with great caution and with the support of parents and a qualified mental health provider.
• The Cass Review recommended that puberty blockers not be offered as routine treatment but be used only in the context of research that has been approved by an independent ethics board to ensure that the rights, welfare, and dignity of participants are upheld.
• Cross-sex hormones should be limited to those 16 years of age or older and prescribed only after a thorough psychological assessment and formal independent review of each case.
• The treatment and support for gender-distressed youth should take a holistic approach that considers all possible factors contributing to patients’ distress – including other mental health comorbidities and neurodevelopmental conditions. As with any other diagnosis, the process must include a differential diagnosis such that alternate causes of the young person’s gender distress are fully examined.
• Mental health support should be the first line of treatment and the medical pathway chosen only after considerable assessment and as a last resort.
The international shift in care
Over the last two years, countries across Europe (Block 2023a), including those among the first adopters of the gender-affirming model for minors, have taken a U-turn. Finland (Terveydenhuollon palveluvalikoimaneuvoston 2020) was the first, followed by Sweden (Socialstyrelsen 2022), Norway (Block 2023b; UKOM 2023) and most recently, Italy (Italian National Bioethics Committee 2024).
Groups of clinicians in other countries, including France (Académie nationale de médecine 2022), Germany (Bundesärztekammer 2024), Belgium and Netherlands (Crisp 2024), and even professional bodies such as the European Child and Adolescent Psychiatry (Radobuljac, Grošelj, Kaltiala et al. 2024), the Royal Australian and New Zealand College of Psychiatrists (RANZCP 2023), and Australia’s National Association of Practicing Psychiatrists (NAPP 2022/2023) have called for a more holistic developmental approach that explores and addresses the physical, emotional, psychological, and social aspects of the patient’s experience. In a move unprecedented among medical associations, the American Society of Plastic Surgeons raised serious concerns about the gender-affirming model, stating that it has “not endorsed any organization’s practice recommendations for the treatment of adolescents with gender dysphoria,” and recognizes that “there is considerable uncertainty as to the long-term efficacy for the use of chest and genital surgical interventions for the treatment of adolescents with gender dysphoria, and the existing evidence base is viewed as low quality/ low certainty” (ASPS 2024). Most recently, government health ministries in New Zealand (New Zealand Ministry of Health 2024) and South Africa (HPCSA 2024) have expressed their intention to regulate and monitor the use of puberty blockers and other pharmacological interventions for youth due to the paucity of evidence about their efficacy and suitability.
Canada’s response to the Cass Review
While there has been some coverage of the Cass Review in Canadian mainstream media (Macdonald-Laurier Institute 2024), only a few articles convey the significance, weight, and meaning of the systematic reviews over individual studies and clinicians’ experience and opinion. The articles rarely explore why the findings of the Review are important to Canadians. The scant and often biased coverage has led Canadians to believe that any questioning of gender-affirming care for youth is simply based on politics.
On October 7, 2024, however, a letter to the editor was published in Paediatrics and Child Health, the Canadian Pediatric Society’s flagship journal (Kulatunga-Moruzi, Mitchell, Palmer, and Goldade 2024). The letter, written by me and three Canadian pediatricians, drew a parallel between the treatment young people received in the UK under the gender-affirming care model and the treatment that Canadian youth are currently receiving. In light of the findings of the Cass Review, it called on the Canadian Paediatric Society to reassess the Canadian Paediatric position statement endorsing the gender-affirming care model (Vandermorris and Metzger 2023). The journal’s response was lackadaisical at best. Rather than carefully appraising the review and its supporting documents – or even getting feedback from its readership, it simply sought a response to the letter to the editor from the authors of the Canadian Paediatric position statement. The response (Vandermorris et al. 2024) does not leave much hope for Canadian youth struggling with gender-related distress. The response doubles down on its original statement and repeats false assertions regarding the Cass Review’s methodology. Vandermorris and colleagues’ response, for example, claims that many studies were excluded because they did not meet ideal methodological standards, when in fact 103 studies were examined, of which 58 per cent were deemed of sufficient quality and included in the report. Cass has already refuted these allegations (Mackintosh 2024).
In responding to the letter to the editor, Vandermorris et al. rely on two articles, a non-peer reviewed white paper on a Yale University web page (McNamara, Baker, Connelly et al. 2024), and a non-peer reviewed preprint (Noone, Southgate, Ashman et al. 2024), both of which contain numerous errors and misconceptions as a recent peer-reviewed British Medical Journal (BMJ) article has pointed out (Cheung, Abbruzzese, Lockhart et al. 2024). Cheung, Abbruzzese, Lockhart, et al. also note that the Yale essay appears to be written to serve a legal rather than a medical purpose.
Two of the criticisms that Vandermorris et al. repeat are that the review is the work of a single individual who does not have any experience treating gender-dysphoric youth. As the BMJ article points out, Cass was selected to head the independent review precisely because she has no experience or stake in treating this population. Such independence allows for impartiality and eliminates conflicts of interest. The critique that the review is the work of a single individual is a gross misrepresentation. While the review does, indeed, list a single author, a team of many experts did the work. The experts included a prominent methodology team at the University of York that was commissioned to carry out the systematic reviews and independent research. The dismissal of this substantive body of work on the basis of such poor reasoning is deeply concerning.
The criticism that there was no consultation with those who treat genderdiverse youth is also misconstrued. As the Review outlined, clinicians who had worked at Gender Identity Development Services at the Tavistock and Portman Trust, the largest and oldest gender clinic in the UK, participated extensively in the review process. Further, LGBT organizations such as LGBT Foundation, 42 Street, Proud Trust, Gendered Intelligence, Mermaids, and Kite Trust conducted some of the focus groups (Cass 2024b). The review consulted all stakeholders, including patients and their families. Vandermorris et al.’s criticism gives the impression that the authors of the response failed to read the Review in its entirety or perhaps without the goal of genuine inquiry.
To support their position that the results of the Cass Review are irrelevant for Canada, Vandermorris et al. claim that the model of gender-affirming care in Canada differs in many ways from the approach that had been in place in the UK, though they do not say how. They state that the Canadian model is drawn from the WPATH SOC8 (World Professional Association for Transgender Health’s Standards of Care, version 8) and the Endocrine Society Guidelines (Hembree et al 2017), which have been treated as the gold standard of care. However, both guidelines failed to use standard methodologies for sound guideline development and instead used weak evidence to make strong recommendations. In a BMJ article published last year, “Gordon Guyatt, distinguished professor in the department of health research methods, evidence, and impact at McMaster University and one of the founders of evidence-based medicine, explained… that with few exceptions, strong recommendations should not be based on low quality evidence. And trustworthy guidelines follow systematic reviews” (Block 2023c). The Cass Review points out in its assessment of the 23 guidelines that the WPATH SOC8 and the Endocrine Society guidelines are not independent and rely upon one another. Both the Canadian model of gender-affirming care as well as that previously practiced in the UK also rely heavily on these guidelines. So, it is unclear how the Canadian affirmation model could differ in any meaningful way.
New WPATH revelations
The WPATH files exposé (Hughes 2024) released earlier this year should give pause to anyone who unquestioningly relies on the SOC8 and the experts who contributed to it. The files reveal that one of the authors of the Canadian position statement (Environmental Progress 2024) admits that many of the youth he treats have not yet studied high school biology and therefore do not have the knowledge or ability to understand and give informed consent to treatment that may compromise sexual function and fertility (Sim 2024).
Further, internal WPATH documents disclosed in discovery in the United States Federal Court case of Boe v. Marshall, a constitutional challenge to an Alabama law banning medical gender transition of minors, reveal that WPATH removed recommended minimum ages for gender-affirming treatments (Ghorayshi 2024) – not based on any scientific evidence but due to pressure from the United States Department of Health and the American Academy of Pediatrics (Singal 2024). These documents also divulged that WPATH had commissioned Johns Hopkins University to conduct several systematic reviews, but then impeded their publication (The Economist 2024) as the evidence did not support the SOC8 recommendations. Further, they interfered with the independent scientific process by insisting on approving the content of all published works. While Johns Hopkins was commissioned to address 13 questions regarding gender-affirming care, only two systematic reviews were eventually published. These discoveries not only call into question the validity of SOC8, but also the integrity of WPATH, which promulgated the SOC8.
Canada’s gender-affirming approach
Both the WPATH and Endocrine Society guidelines recommend careful psychological assessment prior to treatment. A recent study of youth seeking gender services at 10 major hospital clinics across Canada, however, reported that 62.4 per cent of the youth received either puberty blockers or cross-sex hormones on the very first visit (Bauer, Pacaud, Couch et al. 2021). The survey revealed that while some of the youth had discussed their gender distress and were referred to the clinic by health care providers, others only had contact with non-health care providers such as indigenous leaders, religious leaders, school counsellors, or community groups (Trans Youth CAN! 2018). Some youth referred themselves. Most major hospital gender clinics such as Toronto’s Hospital for Sick Children explicitly state that the purpose of the clinic is “to provide information, options and care to pubertal youth experiencing gender dysphoria, which includes assessment and treatment planning. Our clinic takes an affirming approach to gender identity and care” (SickKids Undated). Of the 10 major hospital gender clinics across Canada, five do not even do assessments (Singer 2022). Thus, unlike the young people who receive care in the UK under their new service specifications (NHS England 2024b), there is no opportunity to explore the reasons for the young person’s gender distress, which research shows may be the result of a number of factors including difficulty accepting their sexuality, sexual trauma, abuse, or other mental health issues (Littman 2021).
In February, Radio Canada aired “TransExpress,” an episode of Enquête (RadioCanada 2024). It featured two young women who medically transitioned and are now regretting their decision and detransitioning. Both had undergone a double mastectomy. The episode also gave the viewer a peek at how genderaffirming care may be practiced in Canada – a 14-year-old adolescent female who was able to get a prescription for testosterone in 9 minutes (Turbide 2024)! There is at least one case of a Canadian detransitioner who has filed a lawsuit against her gender-affirming clinicians (Zivo 2023) and Canadian detransitioner stories (Kirkey 2024) are slowly getting coverage in Canadian media (Canadian Gender Report, 2021; Duggan 2024). Some people hurt by gender-affirming care are seeking public support (GiveSendGo Undated a) to fund (GiveSendGo Undated b) their reconstructive surgeries because unlike some transition surgeries, reconstruction surgeries are not covered by public provincial health insurance (Rocheleau-Matte Undated). Young detransitioners are simply asking for reform (Parents and Kids Together 2024).
If gender-affirming care as practiced in Canada is different from that previously practiced in the UK, one wonders what went wrong in these cases. Doctors have a duty to do no harm and to provide sound, evidence-based care. The evidence for gender-affirming care is scant. At the beginning of the Cass Review, Cass discusses the political nature of this area of medicine and how such politicization has been harmful to the young people seeking care for gender distress. The cavalier response from Vandermorris et al. suggests that what happened in the UK is happening in Canada and those who have the most to lose are these vulnerable youth. As the editor-in-chief of the BMJ pointed out, “[p]eople who are gender non-conforming experience stigmatisation, marginalisation, and harassment in every society. They are vulnerable, particularly during childhood and adolescence. The best way to support them, however, is not with advocacy and activism based on substandard evidence. The Cass Review is an opportunity to pause, recalibrate, and place evidence-informed care at the heart of gender medicine. It is an opportunity not to be missed for the sake of the health of children and young people” (Abbasi 2024). This applies across the globe, including Canada.
About the author
Chan Kulatunga Moruzi, MSc, PhD, is a consultant, a contributor to the Macdonald-Laurier Institute, and an independent scholar who focuses on adolescent mental health with a primary focus on gender dysphoria. She has participated in primary research, evidence reviews, knowledge translation, and policy development.
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