Summary

Standing Firm: Why our August 2024 Response to the Cass Review remains our position. The Cass Review was flawed - we said so in August 2024 and what we said has been proven right.

Standing Firm: Why Our August 2024 Response to the Cass Review Remains Our Position

Since publishing our response to the Cass Review in August 2024, TransLucent has faced questions about whether our critique was fair, whether we overstated the Review’s flaws, and whether we should now accept its recommendations as settled science. Today, we want to explain clearly why we stand firmly by our analysis—and why recent international evidence and clinical guidance make our position stronger than ever.

A Growing International Consensus

When we published “Responding to the Cass Review: A Solution-Focused Approach,” we were among the first organisations to undertake a pragmatic “deep dive” and identify systematic problems with the Review’s methodology, evidence handling, and structural bias.

At the time, some dismissed our concerns as advocacy rather than analysis. Since then, however, the international medical and research community has spoken—and it has validated every major concern we raised.

At least seven peer-reviewed articles in leading medical journals have now subjected the Cass Review to rigorous academic scrutiny. The most comprehensive, published in BMC Medical Research Methodology, applied the ROBIS tool—the gold standard for assessing bias in systematic reviews—to all seven York University reviews commissioned by Dr Cass. The verdict was unequivocal: every single systematic review showed high risk of bias, driven by unexplained protocol changes, ambiguous criteria that led to inappropriate study exclusions, inadequate literature searches, and a failure to acknowledge these limitations in the Review’s conclusions.

This isn’t peripheral criticism from outliers. Major international medical organisations have rejected the Cass Review’s evidence base and recommendations. The Endocrine Society, representing over 18,000 specialists in 133 countries, stated bluntly that the Review “does not contain any new research that would contradict the recommendations made in our Clinical Practice Guideline on gender-affirming care”. The World Professional Association for Transgender Health and its US counterpart expressed being “extremely concerned” about the Review, criticising its deliberate exclusion of clinical expertise and systematic misuse of evidence.

Perhaps most tellingly, Dr Gordon Guyatt—the Canadian researcher who coined the term “evidence-based medicine” and developed the GRADE framework central to modern systematic reviews—publicly condemned the use of his work to justify restricting trans healthcare. In September 2025, he called it “egregious and unconscionable,” clarifying that “low quality evidence doesn’t mean it doesn’t work. It means we don’t know”. When the founder of evidence-based medicine says the Cass Review represents a fundamental misapplication of his life’s work, we should listen.

Clinical Best Practice Points: Another Way

TransLucent has always maintained that cautious, evidence-informed care for trans young people is both possible and necessary—but that the Cass Review’s approach goes far beyond appropriate caution into harmful restriction. The recently published German-Austrian-Swiss S2k clinical guideline demonstrates exactly what rigorous, careful trans healthcare looks like when designed by clinicians with actual expertise in the field.

This comprehensive guideline—valid until 2029 and developed through consensus by multiple German-speaking professional societies—takes an individualised, developmentally sensitive approach that centres both safeguarding and the well-being of trans young people. It emphasises exploratory psychotherapeutic support, strong family involvement, careful assessment of consent capacity, and thorough benefit-risk evaluation before any medical intervention. Crucially, it aligns with international standards from WPATHWPATH World Professional Association for Transgender Health https://www.wpath.org and the Endocrine Society while explicitly rejecting the premise that gender-affirming care should be restricted to research settings.

The S2k guideline’s approach to puberty blockers is particularly instructive. Rather than imposing a blanket ban, it recommends careful case-by-case assessment, acknowledging both the limitations of current evidence and the potential for significant harm if clinically appropriate treatment is withheld. It recognises that the low rates of detransition observed internationally—less than 2% when proper protocols are followed—suggest that experienced clinicians can indeed identify young people likely to benefit from medical transition. This directly contradicts the Cass Review’s unsupported assertion that “clinicians cannot tell who will go on to have an enduring trans identity”—an assertion we challenged in our original critique as both implausible and contradicted by the Review’s own audit data.

The Structural Problems We Identified Remain Unaddressed

TransLucent’s 2024 critique highlighted five fundamental problems:

1: Structural bias and exclusion of patient voices.

2: Substandard evidence-based medicine.

3: The implausible claim that clinicians cannot identify persistent trans identities.

4: The indefinite puberty blocker ban without parallel research progress.

5: The failure to assess harms from withholding care.

None of these has been adequately addressed in NHS England’s implementation, even though a highly limiting Puberty Blocker trial has now been agreed.

On structural bias, international critiques have now documented what we observed: the Review team was “explicitly selected for their absence of experience in trans health care,” supposedly to avoid bias, while participants in the Review’s consultations included 32% who agreed “there is no such thing as a trans child”.

As one peer-reviewed article noted, “in the era of nothing about us without us, no Review authors were trans people”. This isn’t balance—it’s the systematic exclusion of relevant expertise and lived experience.

On evidence standards, multiple academic papers have now confirmed that the Review cherry-picked evidence, misrepresented data, engaged in unsupported speculation about pornography and social media, and applied inconsistent standards that treated trans healthcare uniquely harshly. A detailed analysis in the Journal of Medical Ethics explained why the Review’s demand for randomised controlled trials of puberty blockers is both ethically problematic—withholding potentially beneficial treatment from control groups—and methodologically inappropriate for this clinical context.

Most devastatingly, our concern about harms from withholding care has been vindicated. The Coroner’s Prevention of Future Deaths Report following the suicide of 20-year-old Alice Litman in 2022 established a direct causal link between prolonged waits for gender-affirming healthcare and her death. Nearly two years into implementing Cass recommendations, NHS England has still not conducted the robust risk assessment we called for, and the research programme intended to provide access to puberty blockers remains mired in delays.

Our Path Forward

TransLucent never argued against improving services for trans young people—quite the opposite.

Our report was titled “A Solution-Focused Approach” because we offered practical ways to achieve the stated aims of better, safer, more effective care. We called for transparency about who is implementing the recommendations, meaningful involvement of ‘trans experts by experience’, genuinely evidence-based decision-making rather than deference to a flawed report, and restoration of appropriate clinical discretion to specialist practitioners.

These solutions remain the right approach. The German-Austrian-Swiss guideline shows that rigorous, consensus-based trans healthcare is achievable when clinical expertise is centred rather than excluded. International medical organisations have demonstrated that the global consensus supports individualised gender-affirming care, not blanket restrictions. And peer-reviewed research has confirmed that the Cass Review’s methodological flaws are real, serious, and disqualifying

We stand by our critique not because we oppose evidence or safeguards, but because we are committed to both.

Trans young people like the composite “Holly” in our report—forced to endure years of masculinisation that could have been prevented, facing discrimination and conversion therapy attempts, contemplating whether life is worth living—deserve care that is truly evidence-based, genuinely holistic, and actually safe.

The Cass Review, as implemented, does not provide that. The international medical community agrees – we will continue advocating for the care trans young people need and deserve until the NHS does better.