Censorship and defunding, the Cass Review and continental consensuses, scientific updates… our takeaways from EPATH 2025

This year, as two years ago, 13 members of our hospital and community-based teams attended the congress of the European Professional Association for Transgender Health (EPATH), which took place in Hamburg from 3 to 6 September. The teams presented three contributions, focusing on the study by Claire Vandendriessche (community coordinator and peer mediator at TJT), already discussed on our website here, as well as those by Marine Bouron and Alice McGovern (residents in the EPPAT team at Robert Debré Hospital). Marine Bouron’s study was entitled “Comparison of quality of life in young transgender adults according to the timing of masculinising chest surgery: before or after the age of 18”, and Alice McGovern’s was “Exploring the emergence of transgender identity: age and modes of appearance in a self-declared transgender population through an online survey”. Both will be discussed on our website after their publication.

Here are some reflections on selected presentations we attended.

Censorship and massive defunding under Trump: the situation in the United States and worldwide

Asa Radix, an infectious disease physician at the Callen-Lorde Community Health Center in New York and current president of the World Professional Association for Transgender Health (WPATH), spoke about the situation of trans people in the United States since the beginning of Donald Trump’s new presidency.

His intervention, sombre in tone, reflected the depth of despair among trans people affected by Trump’s policies directed against them, both in the United States and across the rest of the world. He recalled that the global prevalence of HIV among transfeminine people is extremely high, around 20 %, corresponding to a probability of infection 66 times higher than that of the general population (Stutterheim et al., 2021). Drawing on multiple studies, he emphasised that access to hormonal and surgical care, as well as to trans-affirming clinical environments, constitutes a highly influential public health lever to improve retention in antiretroviral care, and thus to better combat the HIV/AIDS epidemic within the trans community as well as in the general population. Accordingly, in September 2022 the HHS (US Department of Health and Human Services) recommended that a gender-affirming model of care be implemented in infectious disease services “to improve retention in antiretroviral care and maximise the likelihood of achieving sustained viral suppression.” This was described as a “strong” recommendation, supported by “well-designed non-randomised clinical trials or long-term observational cohort data.”

On 20 January 2025, President Donald Trump issued the following order (Executive Order 14168):

“It is the policy of the United States to recognise two sexes, male and female. These sexes are not interchangeable and are grounded in a fundamental and incontestable reality. […] Each agency and all federal employees must apply the laws […] in order to protect men and women as biologically distinct sexes. […] Agencies must remove any statements that promote or in any way inculcate gender ideology. […] Repeal all documents incompatible with this order.”

Within 24 hours of this order, federal agency websites removed all references to transgender/LGBTQ+ content; the CDC (Centers for Disease Control and Prevention) deleted content referring to “gender,” “transgender,” or “LGBT”; the State Department suspended all new changes of sex markers on passports and reprinted new passports with the previous sex designations, and also removed all “LGBT” content from its human rights reports. The Trump administration also attempted to defund public institutions providing care to transgender minors, an effort that was curtailed by court decisions. Best practice guidelines issued by the HHS, based on the state of scientific knowledge and addressing trans people living with HIV, were removed from federal agencies.

Six days later, another government decree (Executive Order 14187) declared all gender-affirming care to be “mutilating,” ordered the federal defunding of gender-affirming care (including for trans adults), and threatened to fully defund hospitals that continued providing care to trans minors. As a result, 22 hospitals were forced to shut down their specialised clinics.

Between January and August 2025, USD 800 million in budget cuts to NIH (National Institutes of Health) research funding for LGBT health were upheld by the US Supreme Court, which has a conservative majority. Along the same lines, another government decree (Executive Order 14169) froze the PEPFAR fund for the global fight against HIV/AIDS, abruptly cutting off the supply of global health humanitarian services to tens of millions of people living with HIV worldwide. Programmes deemed to promote “gender ideology or diversity, equity, and inclusion (DEI)” were particularly targeted by this freeze, leading to the closure of clinics providing trans people with antiretroviral treatment or prophylaxis (PrEP), mental health care, gender-affirming care, and harm reduction services for drug use – all of which have demonstrated effectiveness in reducing HIV-related risks.

The Cass Review: how independent is it?

German professor of psychiatry Georg Romer, coordinator of the 2025 AWMF clinical practice guidelines for transgender youth (already discussed on Trans Youth Trajectories), returned to the 2024 report by Hilary Cass. In his presentation, he recalled that this report had been commissioned by NHS England (the UK health authority) in order “to improve care for children and adolescents questioning their gender or experiencing gender incongruence,” and that it had been entrusted to a person deemed “independent” (the British paediatrician Hilary Cass), on the grounds of her lack of expertise in the field under consideration (no clinical practice with the population whose care was being evaluated).

Looking at previous “independent reports” commissioned in the United Kingdom, Georg Romer notes that “the independence of evaluators vis-à-vis the services under review was ensured, while being combined with recognition of their expertise in the relevant field. Independence from specialised expertise – that is, the ability to consider a complex field ‘from the outside’ – had not previously been defined as a required quality.” Between the lines, Georg Romer suggests that independence, as it had been conceived prior to the Cass Review, did not amount to ignorance of the field.

Georg Romer then turns to the question of the independence of the Cass Review itself, recalling that only a single author (Hilary Cass) was declared by NHS England, and that no declaration of interests had been published, preventing any assessment of the actual independence of the report from potential conflicts of interest.

Regarding independence from political agendas, Georg Romer recalls public statements made in June 2023 by Sir Sajid Javid, former UK Secretary of State for Health (2021-2022): “I became Secretary of Health in June 2021 […] The NHS had already began an independent review of the GIDS service by Dr Hilary Cass. She was getting close to publishing her interim report, so she had a lot of findings, and so I wanted to meet with her and I asked her to do so. And what I was hearing here was that you were getting these young people presenting themselves to the NHS saying: ‘I think I’m a girl in a boy’s body,’ or vice versa, and instead of questioning, whilst taking this tentatively, it was an affirmative, a completely affirmative approach, it was a self-diagnosis. This was a huge scandal. As soon as I heard all of that I felt that something had to be done. I met with NHS leaders, and I started the process of shutting down the Tavistock.”

According to the former minister’s public statements, Hilary Cass presented him with a catastrophising portrayal of the British hospital-based medical approach providing gender-affirming care to trans minors (the GIDS units of the Tavistock Trust), and did so even before the literature meta-analyses commissioned for the Cass Review and published in 2024 were available. This profoundly calls into question the paediatrician’s supposed independence, particularly with regard to political power. The “huge scandal” invoked by the former minister must be assessed in light of the findings of the audit later conducted by Cass herself and published in 2024: among the population followed at the Tavistock’s specialised GIDS service between April 2018 and December 2022, only 27 % of patients were referred to endocrinology, after an average of 6.7 paediatric consultations (Appendix 8, p. 9). Moreover, among the 3,306 patients included in the audit, Cass observed fewer than 10 cases of detransition, i.e. less than 0.3 % of the patient population (Appendix 8, p. 13).

Without drawing a conclusion on Hilary Cass’s actual or supposed independence from public authorities, Georg Romer states that “despite its recognised merits in offering an overall view of the field and a holistic approach, the Cass Review cannot be considered as – nor substitute for – medical guidelines that comply with international standards of evidence-based medicine.” He instead turns to the definition of evidence-based medicine given by the German Medical Association: “Evidence-based medicine is the conscientious, explicit, and judicious use of the best available external scientific evidence to inform decisions about patient care. The practice of evidence-based medicine involves integrating individual clinical expertise with the best external evidence from systematic research. It rests on three pillars: individual clinical experience, patient values and preferences, and the current state of research.” In short, no one can develop evidence-based clinical recommendations without having clinical expertise in the field concerned.

As examples of evidence-based recommendations, Georg Romer cites the meta-analysis by Meng and colleagues (2022): 82 % of medical recommendations for paediatric off-label drug prescribing are based on uncertain to very uncertain evidence. Yet they are nonetheless recommended as first-line treatments, either because they have demonstrated efficacy in adults, because their safety has already been shown in other paediatric indications, because of a lack of therapeutic alternatives, or because the absence of prescription would be ethically unjustifiable. Romer thus warns against the false equivalence that is sometimes drawn – exclusively in medicine related to gender incongruence – between certainty of evidence and strength of clinical recommendations, as such an equivalence does not exist elsewhere.

Continental consensuses since 2024

Since 2024 and the publication of Hilary Cass’s report, what evidence-based recommendations have been published in continental Europe? In his presentation, Georg Romer identifies five:

• The French recommendations of the Société Française d’Endocrinologie et Diabétologie Pédiatrique (SFEDP), November 2024 (see our summary on Trans Youth Trajectories here)
• The opinion of the Swiss National Ethics Committee, December 2024 (available in English here)
• The recommendations of the European Society for Paediatric Endocrinology (ESPE), December 2024 (see our summary on Trans Youth Trajectories here)
• The recommendations of the Polish associations of sexology, psychiatry, and paediatric endocrinology, February 2025 (available in English here)
• The recommendations of the Association of the Scientific Medical Societies in Germany (AWMF), March 2025 (see our summary on Trans Youth Trajectories here), developed after seven years of consensus work

The AGREE II standard appraisal tool for clinical practice guidelines (Brouwers, 2010) is used by Georg Romer to evaluate and compare these different recommendations, including the Hilary Cass report (see figure below).

Le rapport d’Hilary Cass se distingue uniquement par le développement de revues systématiques de littératures (jusqu’à l’année 2023), un point que seul partage l’AWMF (cette dernière a procédé à des revues systématiques de littérature jusqu’à l’année 2020, qui ont été complétées par l’étude des méta-analyses commandées par Cass).

By contrast, the Cass Review entirely lacks representation from the various relevant disciplines, even though this is a quality criterion in the AGREE II tool. Georg Romer notes that a pediatrician (Hilary Cass) was the sole author, while other relevant disciplines were merely consulted rather than formally appointed as co-authors. Here again, the AWMF stands in contrast: each co-author was formally mandated by a medical or psychotherapeutic professional society (child and adolescent psychiatry, pediatrics, endocrinology, sexology, medical ethics, psychotherapy, etc.).

With regard to the method used to formulate recommendations, Romer points out that Cass did not describe it, and also recalls that the report cannot be considered a “consensus” document (given that it has a single author). By contrast, the AWMF scores highly on this criterion: structured consensus conferences were held, with external moderation and the possibility of submitting dissenting opinions. The strength of consensus is documented individually for each recommendation (above 95 % for almost all of them).

As another quality criterion for clinical practice guidelines under the AGREE II tool, the AWMF performs particularly strongly with regard to external evaluation of its recommendations:

• A transparent online consultation phase (via LimeSurvey) following the first draft version (March 2024), open exclusively to members of the 28 participating organisations (including two patient organisations).
• All comments received and how they were taken into account in revising the draft are published in the methodological report.
• External review and certification of the methodological report by the AWMF institute.
• A revised version, including certain amended recommendations, was ultimately approved by the 28 executive boards of the participating organisations, prior to final certification and publication by the AWMF.

By contrast, on this same criterion, Romer recalls that the Cass Review underwent no external evaluation.

Finally, with regard to conflicts of interest (“COI”), all authors or contributors to the recommendations disclosed their interests; where a conflict of interest existed, this excluded them from being able to lead a chapter of the guidelines. The Cass Review made no declaration of interests, preventing any assessment of its actual independence.

With respect to the content of the continental consensuses from France, Switzerland, the ESPE, Poland, and Germany (AWMF), it is possible to identify both divergences and common points:

• Divergences appear first in the diagnostic phase and psychosocial support. Germany requires a full psychiatric assessment of capacity to consent, combined with parental co-consensus. France and Switzerland favour a multiprofessional approach, with screening for co-occurring disorders and ongoing psychological support. Poland places emphasis on detailed neuropsychological assessment and caution regarding the effects of prolonged evaluation, while the ESPE recommends constant psychosocial support throughout the care pathway.
• Regarding puberty blockers (GnRHa), countries differ in their degree of openness and implementation conditions. Germany allows administration with parental consent even without full capacity on the part of the young person, while Switzerland requires an individualised benefit–risk assessment. The ESPE and France set strict criteria (pubertal development at Tanner stage ≥ 2, expert mental health assessment, informed consent of the young person and parents). Poland follows a similar logic, adding the requirement of continuous psychiatric follow-up. All recognise uncertainties about long-term effects, leading to recommendations for regular monitoring and systematic research data collection.
• For gender-affirming hormone therapy, convergence is stronger: all documents require persistent dysphoria, physical maturity (minimum Tanner stage 2), absence of medical contraindications, and informed consent. Germany and Switzerland nonetheless stand out for greater stringency: in Germany, treatment cannot be initiated without confirmation of capacity to consent, while Switzerland prohibits any proxy decision-making for irreversible interventions. French guidelines tightly regulate biological and vitamin monitoring. Poland considers continuous follow-up by a mental health specialist to be necessary.
• With regard to surgery, Germany prohibits any genital surgery before the age of 18, while chest surgery may be possible during minority following collegial evaluation. Switzerland also explicitly allows the possibility of chest surgery before 18, provided that the young person’s full capacity is recognised.
• Concerning fertility, Germany makes fertility counselling mandatory, Switzerland requires explicit information on potential loss of fertility, and Poland imposes written consent following full information, while France remains more implicit on this point.

Scientific updates of the year

Among the presentations reviewing the year’s scientific developments (“year in review”), Dagmar Pauli’s focused on the mental health of children and adolescents experiencing gender incongruence. Studies show that, in clinical samples, 32 to 78 % of young people present with depressive or anxiety disorders, 13 to 75 % report suicidal thoughts or self-harming behaviours, and 9 to 52 % have already attempted suicide. These rates vary across countries and contexts, but point to significant psychological vulnerability. The most consistent protective factors are family and peer support, as well as lower exposure to victimisation.

The British study by Jarvis and colleagues (2025), involving 3,782 minors experiencing gender incongruence and followed between 2011 and 2021, highlights that despite a recent increase in diagnoses of gender incongruence, the condition remains rare, and only a minority of adolescents receive gender-affirming medical treatments (4.7 % received puberty blockers, 8 % hormones).

International comparisons highlight both cultural variation and common patterns: in several countries (Norway, France, Poland, Israel, Turkey, etc.), the majority of affected young people are assigned female at birth (58 to 86 %), a phenomenon generally explained by transmisogyny, with a mean age of around 15 to 16 years. Adolescents assigned female at birth generally present higher levels of depressive symptoms and suicidal ideation than their counterparts assigned male at birth. Rates of depression range from 23 to 60 %, self-harm from 15 to 70 %, and suicide attempts from 8 to 16 %.

Other research explores the links between gender incongruence, age at clinical presentation, and associated conditions. Older adolescents show higher levels of psychological distress than younger ones, and seeking care at a more advanced pubertal stage is associated with greater psychopathology (Topaz et al., 2024; De Rooy et al., 2024). In addition, around 9 to 10 % of young people followed for gender incongruence also present with an autism spectrum condition, a combination that increases the risks of anxiety, depression, and suicidality. These findings argue for individualised care that takes into account both developmental specificities and neurodevelopmental co-occurrences.

Longitudinal follow-up studies show, on average, an improvement in psychological well-being after hormonal or surgical treatments, notably a reduction in dysphoria, depression, and anxiety. Adolescents who benefit from strong family support and low levels of victimisation derive the greatest benefit from interventions (Chelliah et al., 2025). US-based research (Wittlin et al., 2025) confirms long-term emotional stability and overall satisfaction. Chest surgery in trans adolescents and young adults is associated with significant reductions in depressive symptoms (Ewing et al., 2024). Data on individuals who have discontinued treatment remain limited (Boskey et al., 2025, discussed on Trans Youth Trajectories here), but suggest low discontinuation rates (4 %), associated with more frequent psychiatric disorders.

Finally, Pauli emphasises the complexity of the relationship between gender incongruence and mental health conditions. Two opposing views – considering psychological distress as either the cause or the consequence of incongruence – are insufficient to capture reality, in which biological, social, and cultural factors interact. The minority stress model makes it possible to integrate these dimensions, recognising that chronic stigmatisation contributes to psychological vulnerability. Pauli calls for moving beyond a binary view of treatment success to include identity fluidity and overall quality of life (Oosthoek et al., 2024). An “effective” treatment does not aim for the complete disappearance of gender dysphoria, but for the reduction of stress, the improvement of well-being, and the recognition of young people’s subjective experiences.

In closing, EPATH introduced its new president, Iva Zegura, a psychiatrist in Serbia, who succeeds Annelou de Vries. She recalled that the WPATH congress will take place in Mexico at the end of 2026, and announced the location of the next EPATH congress: Granada, Spain, in 2027.