Dispatches from Deutschland: Cass Not Hip Enough for Germany?
By an anonymous parent of Transteens-Sorge-berechtigt.net
Prof. Dr. Romer, a gender-affirmative adolescent psychiatrist at UKM Münster, CTH, and coordinator of the planned guidelines for minors with gender dysphoria (GD), appears quite relaxed about the predominant role of Germany’s gender-affirmative model. He does not see a need for a significant shift in direction. In an interview with Der Spiegel in April of 2024 titled "Does therapy for trans adolescents in Germany need to change?", he downplays the impact of the Cass recommendations for Germany:
"We were already familiar with all the key recommendations of the Cass Report from previous publications and have taken them into account in detail in our guideline. The nuanced differences between the Cass report's recommendations and our own approach have been blown out of proportion. There is a great deal of agreement between our guideline and the Cass recommendations, particularly regarding the need for appropriate psychotherapeutic care for adolescents suffering from gender dysphoria. There is also agreement on how complex and challenging responsible medical decisions are in this field." (Der Spiegel, 04/23/2024)
Misleading Claims and Absence of Evidence
Romer's claims in the interview are misleading. The relevant therapeutic interventions available in England — exploratory therapy that prioritizes understanding and addressing underlying issues, rather than solely affirming gender identity — are largely absent in Germany, and there are no plans to introduce them. Similarly, German-speaking Europe lacks clear international evidence. Despite over seven years of work, the guideline commission failed to conduct any systematic research or reviews, ultimately producing a downgraded (consensus-based) S2k guideline.
This would have been a significant opportunity for Der Spiegel’s journalist to probe deeper, but for unknown reasons—perhaps due to a lack of understanding of the implications of the final Cass report published just days earlier—she did not challenge his assertions.
NHS vs. German Guidelines
Let us compare Prof. Dr. Romer's statements with the NHS's Implementation Advice from the Cass Review:
Establishment of a research program: The NHS proposes a wide-ranging research program to enhance the evidence base, including studies evaluating the outcomes of psychosocial interventions and masculinizing/feminizing hormones.
According to Romer, there are no plans to conduct such studies in German-speaking countries, despite the weak evidence base.
Holistic assessment: The NHS calls for all children and young people to receive a holistic assessment to inform individualized care plans including screening for neurodevelopmental conditions, and a mental health assessment. The draft German guidelines mention taking note of "depression, anxiety disorder, self-harming behavior, and suicidal tendencies" but places the focus on gender dysphoria/gender incongruence rather than upon comorbidities.
Standard treatment approaches: The NHS advocates for evidence-based psychological and psychopharmacological treatments to manage associated distress and co-occurring conditions, including support for parents/carers and siblings where appropriate. This is partly reflected in the draft guidelines; however, the emphasis is primarily on medical measures, and co-occurring conditions are often attributed to gender dysphoria.
Fertility counseling: The NHS recommends that all children be offered fertility counseling and preservation prior to beginning a medical pathway. Although this is acknowledged in the draft guidelines, 14 professors of child and adolescent psychiatry have criticized the absence of established minimum standards for this counseling in Germany, questioning why it is not mandated.
Follow-up studies: NHS England is tasked with studying the link between services provided by the former Tavistock GIDS and an adult dataset. Germany has not systematically followed up with GD patients, and no future follow-up is planned.
Care for detransitioners: The NHS recognizes the need to create treatment pathways for detransitioners. Currently, there is no established or planned treatment pathway for detransitioners in German-speaking countries.
Age-appropriate services: The NHS has initiated discussions to explore the feasibility of establishing a follow-through service for 17-25-year-olds. This is not addressed in the German draft guidelines.
Restrictions on puberty blockers: In the UK, the prescription of puberty blockers is on hold until further studies are conducted. There are no plans to limit the use of puberty blockers to clinical trials in German-speaking countries, as they are considered part of the standard treatment for gender dysphoria.
Rights-Based vs. Evidence-Based Approaches
Prof. Romer claims that the recommendations of the Cass review were "taken into account in detail in the guideline" and that "the nuanced differences between the recommendations of the [Cass] report and our approach have been blown out of proportion." This assertion is inaccurate.
The most significant difference lies in the emerging trend in England and Scandinavian countries, which are distancing themselves from the primarily "rights-based" WPATH recommendations and gender-affirmative treatment, while the German guideline commission aims to codify these principles for German-speaking countries.
Why is Prof. Romer misleading the public? His assertion in the Der Spiegel interview, that "there is a great deal of agreement in our guideline with the Cass recommendations regarding appropriate psychotherapeutic care for adolescents suffering from gender dysphoria” lacks substance and appears intended to obscure the truth.
The Role of Psychotherapy in Treatment
From our perspective, the comparison of the S2k draft guideline with the Cass recommendations on "appropriate psychotherapeutic care for adolescents" reveals significant differences.
In England and the Nordic countries, the treatment of additional psychological problems, psychosocial care, and exploratory psychotherapy have become the primary therapy of choice for teenagers. In contrast, psychotherapy serves a completely different role in the S2k draft guideline, primarily focusing on affirmative support during the medical transition. Prof. Pauli, a member of the LL Commission, articulated this at the press briefing on the S2k draft guideline:
"The fact is that gender incongruence and gender dysphoria are not mental illnesses, and therefore there is initially no indication for psychotherapy. Of course, psychotherapeutic counseling can be very useful for these gender non-conforming children and trans young people."
Psychotherapy as the sole treatment for GD/GI is often labeled "ineffective" by gender-affirmative experts. The draft guideline1 (footnote p. 109) also states outright (without any references) that, "based on current knowledge, psychotherapy alone is not an effective treatment for gender dysphoria." Additionally, the S2k draft guideline includes the following consensus-based recommendation and warning:
"Psychotherapeutic support should be offered and made available to those seeking treatment as support and guidance—for open-ended self-discovery, to strengthen self-confidence, to overcome experiences of discrimination, or for psychological preparation and follow-up of steps in the transition process. An obligation to undergo psychotherapy as a condition for access to somatic medical treatment is not ethically justified as it respects the dignity and self-determination of the person."2 (page 90)
This passage suggests that psychotherapy before or without a medical transition process is not recommended and may not be permitted at all. This perspective is markedly different from what Hilary Cass proposes.
A Call for Evidence-Based Practice in Guidelines
Evidence from Carl Heneghan, Director of the Centre for Evidence-Based Medicine at Oxford University, regarding the role of evidence in guidelines:
"There's no such thing as 'not enough evidence to do a systematic review,' because what you do is set out a question and try to find all the available evidence. If a review finds only low-certainty evidence, he says, the recommendation should be to 'pursue treatment in the context of a research study addressing the uncertainties'—otherwise, patients will continue to have limited evidence to inform their decisions. A guideline written without a systematic review 'invalidates the guideline as far as I'm concerned,' as without a rigorous appraisal of the evidence 'it comes down to opinion and dogma." 3
S3 Guideline GI/GD p.109
S3 Guideline GI/GD p. 90