The Cass Review: An Analysis

I’ve read it, these are my key takeaways and summary. It’s not good for us, in the UK or elsewhere.

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Research and Research Quality

These are my notes on the reviews research and how it approaches the body of research on trans people and trans youth.

• The review wants “randomised controlled trial” which is not possible with trans healthcare, then uses this to undermine studies based on cohort/cross-sectional studies. How can you do a random trial with a control group here? Do you pick young people at random and give them hormones and placebos? Stop asking for a level of evidence that is impossible to obtain.
• University of York conclude: “No conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development.” That doesn’t mean there are not any: absence of evidence is not evidence of absence (appeal to ignorance).
• Conflation of puberty-blockers (which are reversible) with irreversible medical treatments.
• More appeals to reviews, including… the assertion that psychological interventions are unproven in terms of efficacy? This seems to contradict their recommendation later on for my psychological intervention in lieu of medical intervention.
• References bone density loss from puberty blockers — which is corrected by stopping blockers or taking cross-sex hormones, but this is not mentioned.
• Appeals to “insufficient evidence”… after 25 years? Really? I find that hard to believe. More likely there is a lot of evidence, but because of the nature of the field it’s hard to build evidence of sufficient robustness to satisfy the very high standards demanded by this report.
• Asserts that ‘because most people on puberty blockers go on to take hormones’, then one of their major arguments for their use is wrong — ie that it gives young people time to reflect. “Okay, so we should get hormones earlier, then?” I ask, knowing the answer…
• The report undermines hormone therapy efficacy — possibly for everyone.
• The UK ran an early-intervention study, which produced weird results directly contradicting a similar study in the Netherlands — why? No interest in following that up, apparently.
• Recommends treatment only if it quantitively reduces agreed symptoms, which may be affected by other factors and co-morbidities. So treatments can never be recommended, except in the minority of edge cases where there is no affect from other factors and only where it quantitatively reduces symptoms?
• Studies show improvements in well-being, but because they lacked long-term follow up they were therefore discounted.
• Associates AFAB trans people with “functional tic-like behaviour” and misquotes its own source, leaving out the words “PROBABLY LED TO” (Nilles at al 2022) when making a link between FTLB and social media influence, implying it was a direct causality.
• Muddies trans with other issues to refute mental health/suicidal thought improvements, and so can use this to discount improved mental health and lowering of suicide risk ie we don’t know if trans affirmation helped you are just other things in your life improved.
• Identifies that many people stop identifying as trans in their 20s… but doesn’t interrogate why and what aspect societal pressure and just “getting on with it” has, especially with such long waiting lists.
• The report includes an obvious feedback loop: Nordic countries are becoming more cautious… based on the NHS becoming more cautious, which is now feeding into this very report! THAT ISN’T SCIENCE.
• And yet the report discredits WPATH and Endocrine Society because they refer to one another and build on each other’s findings.
• Reference to “formal tools to measure gender dysphoria”… I’d love to see how you measure that in a controlled, quantitative way as desired by Cass.
• The report says puberty blockers improving well-being has “no strong support”… so not ‘no support’, huh?
• So few studies meet the University of York’s inclusion criteria. What is the point?
• blah blah studies aren’t good enough because reasons, even though they demonstrate positive improvements.
• Out of 3499 patients audited, < 10 detransitioned.
• Backs up puberty blockers for passing in later life for trans women.
• Wants more research, more time. All whilst trans people’s lives slip away and youngsters become adults.
• Incorrectly states that benefits/harms of puberty blockers and hormones are unknown. There is evidence, it just isn’t up to the standards of this review. That doesn’t mean it does not exist and has no value.

Trans is Bad

The review makes several references to things that I feel betray the underlying assumption that being trans is bad and must be avoided at all costs.

• Why do increasing patient numbers over 5 years need explanation?
• Very much paints trans as the “last thing that should be treated”, only after all other factors are accounted for.
• Links early social transition with medical transition — well duh, right? They’re trans.
• What other procedures are held to this standard? eg breast augmentation, available to any 18 year old?
• …you can’t be autistic and trans apparently.
• links online/social media use to mental health problems to trans-ness. And throws in porn for good measure.
• again with the FTLB and “learning it online”.
• Goes right up to the line of endorsing rapid onset gender dysphoria, but stops short by saying “guess we need more research”.
• Review highlights attitudes of “born that way” vs “social contagion” and concludes that the truth must be somewhere in the middle. Oy vey.
• References influencers impacting kids’ decisions to be trans.
• OMG social transitioning leads to medical transitioning! DUH. They’re trans.

Conservative

Several points just come under the general banner of being very risk averse and conservative.

• Labels social transition as treatment/intervention
• Centres parental views
• Focus on feedback from many NHS staff — plenty of whom are gender critical.
• Recognises people don’t want stigmatising diagnosis, but doesn’t recommend letting them just choose their own options.
• Recommends more therapy. Even though being trans is not a mental illness…
• References a “suggestion” that detransitioning is increasing, with no evidence.
• Recommends 10–15 years to extract needful data and research.
• Intervention must be “clinically indicated”…
• Intervention must be discussed at a multi-disciplinary team by the national provider collaborative. Yikes.
• Keeps emphasising patient autonomy and choice whilst gatekeeping and slowing them down.
• Re-litigates Bell v Tavistock: “okay, maybe she was competent but the doctors shouldn’t have let her do it”, because it wasn’t clinically indicated.
• Accepts children at 15 will make similar decisions to adults, but continues to talk about 25 as a cut-off point for autonomy.
• Increase in trans young people can’t be down to increased societal acceptance because it’s not adequate explanation: why? The reasons for dismissing this are very subjective.
• Re-affirms that the NHS must see social transition as an ACTIVE INTERVENTION. Makes reference to the schools guidance previously issued. Highlights parental panic about children doing stuff without their involvement — parents felt “forced to accept” their child’s identity or risk being transphobic/unsupportive.
• More reference to exploration, flexibility and experimenting (a Good Thing) which is at complete odds with the rest of the report.

“The authors of the study concluded that as long as debate remains on these seven themes and only limited long-term data are available, there will be no consensus on treatment. Eight years later, the position is unchanged and many of the same considerations apply to the use of masculinising/feminising hormones in young people.”

Uh-huh. Soon to be applied to adults, I wonder?

• Concerns about puberty blockers affecting neurological development — but no EVIDENCE. Just what ifs.
• Affirms that the clinician will always be liable.
• Recommends an EXTREMELY CAUTIOUS appreach to hormes from 16–18. Conclusion for BROADER RESEARCH PROGRAMME to build evidence on ALL POTENTIAL INTERVENTIONS.
• At the adult gender identity clinics, “a number of staff” reported “concerns” about more AFAB trans people since 2017 + neurodivergence + trauma etc. and an increasing number of detransitioners. No numbers, no facts, just concerns.
• Recommendation: bring forward update of the ADULT service specification and review model of care and operating procedures. Great. There goes my healthcare.

Controversial

Some aspects of the report are just out-and-out controversial, by which I mean they’re likely to make people sit up and go “huh… I see?” and question some of the motivations behind the review.

• Adult gender services did not co-operate, so limited evidence base.
• Various GIDs expressed concern about how this report will be used, its political influences and rejecting the need for better safeguarding.
• Recommends changes to adult services
• The report keeps coming back to sexuality… which is nothing to do with gender identity and putting the two together is a strange place to be in.
• Highlights that some parents report their kids were in a “phase” and were just lesbians. This gets its own bullet point… which is interesting. No mention of how many or if it is corroborated.
• Lends a lot of credence to the “it’s easier to be trans than gay” argument.
• Asserts that puberty blockers are safe for cis kids but not trans kids… because early-onset puberty is unusual and regular puberty isn’t. Huh.
• Asserts that “gender euphoria” is caused by increased libido when starting hormones… really.
• Regarding trans suicide, the review says that there is “no evidence affirmative care reduces this”. Mostly because it tangles trans identities up with mental health co-morbidities.

Social Contagion

Yep, this is right here under the surface. The report mentions — without evidence — “peer influence” and “sex of rearing”. Yes, young people decide to be trans because they saw it online and if parents affirm them then they are just turning normal, healthy girls into boys or vice versa. Apparently you can learn to be trans, according to Cass.

Gatekeeping

Being a very conservative review, naturally the document brings up even more gatekeeping, especially for those of us who are neurodivergent.

• Recommends screening for neurodivergence
• Puts onus on pharmacists to ensure medications are suitable
• Draws line between NHS and private care — if you do one, you can’t do the other
• More committees, more boards, more committees to appoint boards etc.
• Concern about private prescription of puberty blockers
• Doctors must decide if treatment is “clinically indicated”
• Recommends that dysphoria be resolved in ways other than medical intervention.
• “Brain maturation continues into mid 20s”.
• A lot of input from lived experience groups who want an informed consent model… but this is instantly shut down without argument because of GMC (2021) ‘responsibilities of prescribers’ and GMC (2018) ‘safeguarding of minors’.
• Due to the backlog in referrals, many young people go straight to adult services by aging out. The review recommends stopping this by introducing a ‘follow through’ service in-between, covering up-to 25 year olds.

Naïve

There are several points in the review that I can only describe as naïve, like Cass was born yesterday.

• No acknowledgement that proposed new services have yet to open, despite old ones being closed.
• These services have been underfunded and cut so much that the waiting lists now stretch into multiple years, so by the time young people get to them, they’re desperate for help and this may lead to suboptimal, rushed decisions. Well bloody fund these services, then.
• The review recommends that young people can’t get treatment unless they are likely to go on to have a longstanding trans identity… so no room for exploration, then? We’re back to an all-or-nothing approach?
• It ignores lived experience feedback who want medical and exploration services available concurrently.

“Transgender males masculinise well on testosterone, so there is no obvious benefit of puberty blockers in helping them to ‘pass’ in later life, particularly if the use of puberty blockers does not lead to an increase in adult height.”

…apart from removing the possible need for a double mastectomy????

“For transgender females, there is benefit in stopping irreversible changes such as lower voice and facial hair. This has to be balanced against adequacy of penile growth for vaginoplasty, leaving a small window of time to achieve both these aims.”

Not all trans women want vaginoplasty, for various reasons, and puberty blockers have been blanket banned — even though Cass concedes here is a very real, practical use for them!

“In summary, both young people and adults presenting with gender dysphoria often have complex additional mental health needs. It is hard to know the extent to which hormone treatment mitigates these issues, and the role played by treatment and support in the additional ongoing mental health issues.”

…so we shouldn’t do it… Everybody got that?

“A systematic review of suicide-related outcomes following gender-affirming treatment (Jackson, 2023) reported that in a majority of studies there was a reduction in suicidality following gender-affirming treatment. However, there were major methodological problems in most of the studies, with the biggest problem being a failure to adequately control for the presence of psychiatric comorbidity and treatment, such that no firm conclusions could be drawn”

Again, I’d love to hear how can you control for this. It is a very convenient way to completely write-off the study, though.

• Talks about new service models — despite none of the new centres being open yet
• No guidance for dealing with the massive backlog of referrals
• Predictably, the lions share of the review is devoted to admin/organising/bureaucracy around setting up new centres. Catnip for NHS apparatchiks.
• Recommends more training and bigger workforce. I’d love to see that happen, but I suspect some bits of this review will be emphasised a lot more than others.
• “Embed clinically based research into regional centres”… trans people aren’t guinea pigs.

Contradicted by own cited papers

Indeed, Cass is even contradicted by some of the very papers she cites:

“Gender identity problems have wide-reaching implications for children and their families and problems may become more entrenched with the onset of puberty. Although specialist support and co-ordination of services becomes essential particularly at this time, interventions in childhood may have the function of preventing difficulties becoming more severe during adolescence.” (source)

and:

“Moderate-quality evidence suggests mental health may be improved during treatment, but robust study is still required.” (source)

Just Wow

The entire point of the Gender Recognition Act is to allow trans people to live in their correct gender without exposure, and yet…

“The Review’s quantitative research programme, led by the University of York, aimed to improve the evidence and provide a better understanding of the treatment approaches for this population of children and young people. The research aimed to do this by tracking the journeys of young people who were seen by GIDS into NHS adult gender dysphoria clinics
and the wider health system, to provide a population-level evidence base of the different pathways.

The Secretary of State for Health and Social Care granted an order under s22(5) of the Gender Recognition Act to enable data to be disclosed for a time-limited period for the sole purpose of the study. Like all NHS research, the study was subject to strict ethical and legal controls with an ‘opt out’.”

So unless you explicitly opted-out, you got your identity exposed for the purposes of this study. That sounds good and ethical.

Summary

The Cass Review:

• Throws away research on unclear grounds of quality.
• No recommendation for how to obtain “good” research given the nature of this subject.
• Goes right up to line of endorsing rapid onset gender dysphoria.
• Panics over rise in AFAB trans people.
• Panics over neurodivergence.
• Identifies affirmation as “treatment”.
• Recommends extensive therapy and not-trans-related care up until at least 16, ideally more like 25.
• Undermines WPATH and Endocrine Society for spurious reasons.
• Doesn’t highlight which groups and bodies were consulted.
• Ignores feedback from lived experience patients, despite quoting them.
• Highlights need for more staff, more money and more facilities — let’s see how many politicians emphasise that.
• Undermines puberty blockers and hormone treatments by throwing out research rather than interrogating it more critically.
• Hand-waves away the lack of involvement from many GICs that had serious concerns about this report.
• It will be used to basically ban trans healthcare for under 20s for the next decade.
• It will be cited by other countries to do likewise, which will then feed back into this as more evidence trans healthcare shouldn’t be pursued.
• It will be used to trigger a review into adult trans healthcare.
• Labour has already said they back this 100%.

Sorry trans kids, you’re going to need to grow up in the wrong gender presentation before you can get help — which will as a result be a lot more invasive, expensive, time-consuming etc.

Like a lot of trans people, I’ve researched and studied a lot of the literature, debate and research around this. I’ve written many times on this subject, from the perspective of society; politics and science. It is upon that which I have done my analysis. I’m not a doctor, nor a lawyer, so take what I say with a pinch of salt.