New Report Says Cass Review Should Not Be Benchmark For Trans Healthcare in Australia

A major new peer-reviewed Australian report warns that the UK’s Cass Review is fundamentally ill-suited to guide care for trans young people — and should not be adopted as a benchmark in Australia.

Authored by an Australian and international team of clinicians, ethicists and researchers, the report argues that the Cass Review’s recommendations are plagued by methodological, conceptual and ethical flaws — and that applying them to Australian care for trans and gender-diverse youth would risk harm, restrict access, and undermine best practice.

“The Cass Review, lacking expertise and compromised by implicit stigma and misinformation, does not give credible evidence‐based guidance,” reads the review’s conclusion. “We are gravely concerned about its impact on the wellbeing of trans and gender‐diverse people.”

The scope and mismatch of Cass Review with Australian context

The Cass Review was commissioned in the UK in response to growing referral numbers, criticism of existing gender identity services, and a high-profile legal case (Bell v Tavistock).

Its final report, released in April 2024, proposed sweeping restrictions: puberty suppression (GnRHa, also known as puberty blockers) only via clinical trials, tighter controls on oestrogen and testosterone for under-18s, and casting doubt on social transition as potentially harmful.

In Australia, gender-affirming care is recognised as best practice, and national guidelines are under review to update standards for trans and gender-diverse children and adolescents.

The authors caution that importing the Cass framework wholesale would do violence to the country’s existing multidisciplinary and person-centred model.

Internal contradictions and inconsistent logic of the Cass Review

A key critique is that the Cass Review contradicts itself. For example:

• It concedes that some young people benefit from puberty suppression, yet its recommendations make access to GnRHa essentially unavailable.

• It finds no solid evidence that psychological or psychosocial treatments relieve gender dysphoria, yet recommends expanding those interventions.

• It labels evidence supporting gender-affirming medical treatment (GAMT) as “weak”, while speculatively emphasising potential harms — but fails to evaluate the harm of withholding care.

In other words, the Review simultaneously acknowledges benefit and then undercuts it with its own prescription of greater restrictions.

Treatment restrictions: puberty suppression and hormones

Puberty suppression (GnRHa)

The Review insists that GnRHa should only be prescribed within a clinical trial — a move that would make the therapy inaccessible unless a trial is established, which so far has not occurred. Its approach ignores longstanding practice in other jurisdictions and downplays observational evidence showing psychosocial benefits and acceptable safety profiles.

The authors of the critique argue this fails to appreciate the real therapeutic goal of GnRHa: preventing irreversible pubertal development incongruent with a young person’s affirmed identity, such as (but not limited to) breast growth or voice changes.

Oestrogen and testosterone for minors

Under implementations from the Cass review, trans adolescents aged 16–17 would need approval from a “national multidisciplinary team” and must be approached “with extreme caution”, further lessening trans people’s access.

The Review itself notes that, historically, UK paediatric services were already restrictive, with only about 22 per cent of assessed patients being prescribed GAMT. Imposing further barriers, the authors argue, is unjustified given that many adolescents derive essential benefit from it.

Social affirmation and framing as intervention

One of the more controversial aspects of the Review is its framing of social transition — using chosen name, pronouns, clothing, and school changes — as an “active intervention” that might itself do harm, rather than a support for identity.

This pathologises what many in trans health see as foundational steps: recognition, affirmation, and dignity. The Review goes so far as to suggest that families considering social transition should be referred to a clinician early — opening the door to gatekeeping, repressive counselling, or even conversion-style approaches.

Yet observational and longitudinal evidence consistently shows that social affirmation is associated with improved mental health, reduced distress, and better wellbeing.

Evidence limitations, bias and exclusion

Cass commissioned seven systematic reviews, but the authors of those reviews were limited: their searches cut off in April 2022. The critique argues that more recent observational studies — showing higher satisfaction, mental health improvement, and safety — are being ignored.

No authors of Cass were trans, and selection criteria explicitly excluded those with prior involvement in trans health, purportedly to avoid bias. The critique contends this led to conceptual blind spots and reliance on speculative, cis-normative assumptions.

When consulting lived experience, the Cass Review recorded distress over access barriers but largely omitted youth voices of benefit, instead prioritising speculative concerns from cisgender adults.

The authors and contributors of the Australian report are health professionals working in gender‐affirming health care for transgender (trans) young people and other fields, and it also makes a note that “some are trans, gender‐diverse and non‐binary, and some are cisgender (not trans); some are queer and some are straight, [and] are from a range of cultural and language backgrounds; some are early career and some are senior”.

Cass also prioritised the prevention of regret as a central framing, even though regret is very rare among those who undergo gender-affirming care. There is no clear evidence that restricting GAMT reduces regret — in fact, the authors of the Australian warn that such restrictions may drive unsafe self-treatment or deepen distress.

Implications for Australia and recommendations

The authors do not reject all of Cass’s 32 recommendations — some align with current Australian practice, such as multidisciplinary and family-centred care and the importance of fertility discussions.

But the report believes many of Cass’s restrictive elements directly clash with evidence-informed, person-centred care in Australia.

Instead, the authors urge Australia to:

• Continue updating national guidelines through the National Health and Medical Research Council review, with co-design and trans inclusion

• Honour youth voices and lived experience in policy and practice

• Support ethical, well-designed research without making care contingent on trials

• Guard against ideological or moralistic interference in trans health

They conclude: “The Cass Review, lacking expertise and compromised by implicit stigma and misinformation, does not give credible evidence-based guidance.”

What this report means for the community

For trans and gender-diverse young people in Australia, this report is a call to vigilance.

While the global debate continues, best practice in our context demands that we hold fast to care grounded in inclusion, evidence, respect, and importantly, we prioritise the voices of those with lived experience.