Doctors question Cass report’s dismissal of ‘poor quality’ trans healthcare research

A group of Canadian doctors has questioned the Cass report’s decision to disregard a large number of existing studies into gender-affirming healthcare.

The Cass report on the model of trans youth care in England was published last week. NHS England commissioned paediatric expert Dr Hilary Cass to head the review in 2020, in response to the sharp rise in referrals to what was then England’s only youth gender clinic.

Following an interim report published in 2022, Cass recommended a “holistic approach” to treatment, including the creation of regional hubs across England.

Reaction to the report was a mixed bag of praise and criticism from experts who say that, while the report was needed, several of its findings and recommendations are questionable.

One of the biggest concerns is the report’s assertion that almost all existing research into clinical guidance for trans youth is of “poor quality” and that there isn’t “a reliable evidence base, upon which to make clinical decisions,” including through international guidelines.

Dr Tehseen Ladha, a paediatrician and assistant professor at the University of Alberta, has questioned this approach to handling clinical research.

She told CBC that paediatric research is often imperfect, as is the case in many other medical fields, because of systemic blockages.

“That is the case in almost every sphere of medicine because the cost, time, feasibility and ethical ability to conduct what is considered a high-quality scientific trial, is just not there,” she said.

Finding perfect evidence is especially difficult when dealing with a marginalised population because those groups often “haven’t been thought of as priorities or important,” Ladha added.

Gold-standard research ‘not always feasible’, paediatric expert says

Among the organisations that the Cass report dismisses as “poor quality” is the World Professional Association of Trans Health (WPATH), an internationally recognised think tank on transgender healthcare.

The report labels WPATH as lacking in “developmental rigour” despite being “highly influential in directing international practice.”

WPATH has been integral in influencing guidance in several countries.

Dr Sam Wong, the president of the Alberta Medical Association, said that one of the gold-standards for a high-quality study is a randomised and controlled trial in which neither the patient nor the doctor knows if the medication is a placebo.

But, beyond ethical considerations, it would be difficult to recreate this with trans healthcare, he explains.

“Within a few months, it’s obvious to the person that they’re on puberty blockers or they’re not,” he said.

“They have feelings and they have impressions of what they should be going through. That’s going to influence the study itself.”

Wong went on to say that puberty blockers have been used “for decades” and, when prescribing them, side effects are always made clear to parents and children.

“There are side effects with every medication, and I would talk about the side effects. But for the most part, it’s a safe medication.”

Dr Jake Donaldson, a family physician from Calgary who has previously prescribed puberty blockers and hormone therapy to trans patients, argued that not having randomised clinical trials shouldn’t be a reason to withhold care.

“There actually is a lot of evidence, just not in the form of randomised clinical trials,” he said. “That would be kind of like saying for a pregnant woman, since we lacked randomised clinical trials for the care of people in pregnancy, we’re not going to provide care for you.… It’s completely unethical.”