Phony And Genuine Narratives Of Distress In The Cass Report

How The NHS Is Entrenching Institutional Transphobia

Introduction

The purpose of the Cass Review is described on its website as follows:

The Review was commissioned by NHS England to make recommendations on how to improve NHS gender identity services, and ensure that children and young people who are questioning their gender identity or experiencing gender dysphoria receive a high standard of care, that meets their needs, is safe, holistic and effective.

After a four year process, the review’s extensive final report was released in April 2024. Since then, it has attracted a large number of extremely harsh critiques and condemnations.

Those critical responses are detailed here:

What’s wrong with the Cass Review? A round-up of commentary and evidence

That article shows a plethora of academic reviewers, professional bodies, and trans community organisations that stand in agreement that there were fundamental failings with the way the review was conducted, with the approach it used to weighing evidence, and with the conclusions and recommendations it put forward.

I’ll explore some of those identified problems in this article, but my primary focus is on the rhetoric used within the Cass Report. By examining how topics were framed, we can see how the narrative of the report is skewed at the most fundamental levels: hostility to trans people is baked into the very terminology of the review.

For example, I will analyze how Cass weaponizes the term “distress” by using it metonymically to stand in for trans existence, thereby baselessly and grotesquely implying that mental incapacity and instability of identity are defining attributes of trans people.

These insinuations, along with the inexactitude of the term, are used to cast doubt on all aspects of medical care for trans people, regardless of evidence base.

I’ll show how a focus on “distress” was used to obfuscate the core purposes of treatments in transgender care. By keeping the reader’s attention on a subset of a treatment’s (often hypothesized) effects, Cass elides ancillary outcomes with the reasons why those treatments are used. The centering of tangential aspects of medical treatments renders the report’s evaluations of evidence and recommendations broadly worthless.

I’ll also explore various other rhetorical and procedural tricks used by the report, giving insight into how flimsy its underpinnings are.

In addition, I’ll outline some of the numerous narratives within Cass that recycle “classic” homophobic views. Recast as anti-trans talking points, the modern iterations of these stale fables were apparently received with utter credulity by the Cass Review. It is striking that a complete neophyte in the field of LGBTQ+ healthcare was appointed to lead this highly sensitive report, and that she failed to collaborate or consult with queer advocacy organizations.

The is a report completely contaminated by bad ideas and worse reasoning.

Despite the uproar Cass has generated — including the BMA raising concerns and embarking on an evidence-led evaluation of the report — the NHS is already acting upon the basis of the report’s recommendations.

BMA to undertake an evaluation of the Cass Review on gender identity services for children and…

To do so is to acquiesce to a mendacious, weaponized portrayal of “distress” while ignoring the genuine distress induced by the social and medical experiences that patients suffer through.

Those experiences can be glimpsed by sifting through the accompanying matter of the Cass Report. I will show some examples and make it apparent that Cass does not just fail to centre or act upon patient concerns but that she makes recommendations that will directly exacerbate those reported issues.

It is urgent to understand that implementing Cass will entrench deeply transphobic ideas and practices within the NHS. The result will be a systematic and dangerous failure to serve the needs of a patient group that is marginalized, maligned, and misunderstood at every turn.

Weaponized Narratives Of “Gender Related Distress”

How Cass Wrongly Characterizes What Trans Healthcare Is For

The Cass Report repeatedly misrepresents transgender healthcare as consisting of “interventions to manage gender-related distress”:

From the Foreword to the Cass Report, setting things up as a two sided “debate” of som kind.

The term “gender-related distress” is used 54 times in the final report¹. It is one of the key mantras of the document, used as the foundation for a wide variety of narratives that actively misrepresent both trans people and the nature of the healthcare that they access.

The report is framed with the notion that a desire to “resolve” distress is the primary or sole reason why patients seek help:

From the “About This Report” section of the Cass Report

However, trans healthcare cannot fundamentally be about managing or resolving distress. We can immediately and completely undermine this notion by considering diagnostic criteria — dual standards for which are laid out only in Appendix 10 of the report.

No substantive analysis of how these standards evolved, or the differences between them, was made by Cass.²

The condition of gender incongruence in the ICD-11 standard, a modern (2022) diagnostic classification system published by the World Health Organization, does not require any expression of distress.

ICD-11 has entirely discarded the pathologizing idea that being trans is a mental health condition. Earlier iterations of the standard did the same in respect of “homosexuality”, which was similarly pathologized.

The condition of gender dysphoria in the DSM-5 standard, an older (2013) diagnostic classification system published by the American Psychiatric Society, also does not require distress to be expressed.

It is diagnosed on the basis of symptoms that must be associated with either distress or “impairment in social, occupational, or other important areas of functioning”.

Societal marginalization of trans people can create social and other “impairment” issues for patients, which medical care can help to address. It is not the case that trans people with gender dysphoria have to be innately distressed as either a cause or consequence of being trans.

Extract from APA guidance on gender dysphoria diagnosis for transgender and gender non-conforming people. See https://www.psychiatry.org/psychiatrists/diversity/education/transgender-and-gender-nonconforming-patients/gender-dysphoria-diagnosis

This means that the central focus of care for trans patients therefore simply cannot be the “resolving” of distress — by definition that does not address the health needs that patients may have as a result of being trans.

It is very important to note that ICD-11, which is the modern global standard for disease classification in general, puts gender incongruence in the category of sexual health, not mental health. ICD is the diagnostic standard used by the NHS³.

This implies that trans healthcare services should operate as a form of sexual health service, not as a psychiatric fief — the latter being very much the historical, stigmatizing model of trans healthcare. As we will see, Cass is firmly committed to the retrogressive move of consolidating that fiefdom, and early steps in implementation of the report’s recommendations have already introduced new barriers to care on this basis.

How Cass Uses A Framing Of Universal Patient Distress To Launder Transphobic Narratives

It might be suggested that Cass is simply using “gender-related distress” very loosely, as a synonym for “gender dysphoria”.

This is not the case, as Cass clearly differentiates between gender incongruence/dysphoria, and gender-related distress:

Presenting “gender-related distress” in this way, as something ubiquitously experienced by patients of the service, regardless of a specific diagnosis or lack of it, allows Cass to advance three separate narratives.

Firstly, the vagueness of “distress” as a condition means that Cass can imply that all patients can be “cured” (via distress “resolving”) with generic treatments such as anti-depressants, contraceptives, or endless (useless) ill-defined “therapy”, to be substituted for the use of trans-specific medical interventions such as puberty blockers or hormone therapy. This directly plays to the old canard that being transgender (or otherwise LGBTQ+) is a form of mental illness. (See, for example, §5.39, §8.42, §11.33, §11.34, §14.55 and the curiously emphasized linking of “distress” with such approaches in Recommendation 3).⁴

• Secondly, Cass casts doubt over the patient’s ability to exercise choice about their care by suggesting that “distress” (especially in combination with the medical treatments that trans people seek out) makes people incapable of thinking clearly. Cass uses a rhetoric of infantilization and saneism to imply that trans patients cannot be competent to exercise choice about the treatments they wish to access. (See, for example, §63, §15.28, §16.10, §16.27, §16.29). Section §14.38 even introduces the catch-22 argument that no one can ever be mature enough to consent to the use of puberty blockers on the sole basis that “brain maturation may be temporarily or permanently disrupted by the use of puberty blockers”. This is flagrant fearmongering: there is no compelling evidence advanced in support of these purely hypothetical dangers (hence the risible appeals to ‘unintended and as yet unidentified consequences’ in §14.35 and ‘unknown unknowns’ in §16.18). Likewise, myths about brain development are presented as though they are uncontentious truths (§§6.32–6.44), in order to suggest that mental competence in respect of trans healthcare decisions cannot be achieved before the age of 25 years old. This is nothing more than a semi-concealed assault on Gillick competence — and beyond that, on bodily autonomy for adults.

A Powerful Idea About Our Brains Stormed Pop Culture and Captured Minds. It's Mostly Bunk.

• Thirdly, by characterizing all patients of the service as suffering from “distress”, Cass suggests that those who are not transgender are simply following a “pathway” or “trajectory” to not-being-trans that is available to everyone. This narrative encourages thinking about how “distress” might be actively suppressed: if some patients “resolve” it by not transitioning, why not all? The report’s disproportionate interest in “detransition” illustrates that Cass does not regard the personhood of trans people as authentic. A striking example is provided by the confabulation of §16.20, which suggests that a trans man who has been forced through an unmediated puberty somehow would become “an adult cis-woman” which might “cause them to regret or detransition”. This is utter fantasy — it embodies the bigoted belief that there is a pathway to “cure” LGBTQ+ people.⁵

These three narrative themes about “distress” plainly incorporate many of the familiar tropes of transphobia⁶.

The reason such open prejudice could make it to publication without any pushback is that trans patients and representative groups were deliberately excluded from governance or any other form of oversight of the report. There really were no effective guard rails against bias in the whole process — and it shows, vividly.⁷

The well-rehearsed strands of anti-trans bigotry that are obviously embedded throughout the report appear to be entirely invisible as such to the (overwhelmingly, perhaps exclusively) cisgender eyes of officialdom: both NHS management and Wes Streeting immediately pledged to implement all of the report’s recommendations, a reaction of unseemly haste that stands in sharp contrast to the endless stonewalling that is the standard response to trans critiques of the NHS.

How The NHS Characterizes The Aim Of Trans Healthcare, And How Cass Works Against That Aim

“Help People Live The Way They Want To”

In contrast to the “resolve distress” framing that Cass uses, the current NHS page on gender dysphoria sums up what treatment genuinely should do:

To allow the patient live the way they want to, to help them comfortably exist: that is the point of all transgender healthcare interventions, from hormone therapy to electrolysis, voice training to gender-affirming surgery.

To be effective, trans healthcare should be designed to support trans people in the exercise of bodily autonomy: to allow for the pursuit of a worthwhile, liveable life. And effective is precisely what transition is — we know that trans healthcare succeeds spectacularly at improving patient life satisfaction and well-being.

Survey of over 90,000 trans people shows vast improvement in life satisfaction after transition

What does the scholarly research say about the effect of gender transition on transgender…

“There Are Different Views”

Cass, on the other hand, clearly does not aim to “help people live the way they want to”, as the report’s discussion of social transition (ST) shows.

ST is simply the action of adopting preferred manners of dress and address; it is an absolutely fundamental component of a trans person living “the way they want to”.

Cass repeatedly casts doubt on the notion that ST should be undertaken. Chapter 12 extensively pitches the idea that social transition is the business of clinicians — something they should intervene in with the aim of “keeping options open” (as if social norms don’t already exert incredibly intense pressure to not transition).

Early in the report, §74 directly expresses concern that ST could affect the “trajectory” of gender development, causing potential “harm”. This hypothetical harm cashes out, simply, to being transgender (life-long medical intervention in this case is simply regular hormone treatment; despite the rhetorical flourish this is no more ghastly than, say, people with bad eyesight having to undergo life-long medical intervention in the form of wearing glasses).

Cass apparently literally believes that clothes maketh the man (or other gender of your choice). Or maybe it is the pernicious effect of pronouns?

The reliance here on what “others consider” to be the case seems a fairly sparse evidential basis in favour of the fantasy that ST might somehow prevent gender dysphoria from spontaneously resolving — which is very obviously a modern reworking of old-fashioned homophobic rhetoric.⁸

The report itself is a little shy about identifying who the “others” in “others consider” are, but if one digs into the accompanying “systematic review” on social transition, the sole support for this notion is a short opinion piece by Kenneth Zucker.

Anyone familiar with Zucker’s history with respect to “social transition” can see that Cass is simply reiterating the mistakes of the past, by treating as credible “sexology” assumptions about gender malleability which have long been discredited. These ideas turned out to be wildly incorrect; they led directly to the abuse of children through conversion practices and the closing of Zucker’s clinic. (Note that Cass is aware that “malleability” has long been rejected, as per §2.14).

Discredited treatment of trans kids at CAMH shouldn’t shock us

Dr. John Money Gender Experiment: Reimer Twins

Citing Zucker’s opinion as part of discussion around “social transition” suggests approbation for rebooting an era of performative cruelty, in which enforcing conformity to gender norms was attempted through actions such as withholding toys from children, or enacting parental cruelty.

The expectation that being cruel would somehow chase transgender identity out of existence (“resolve distress”) was and is incorrect. All it does is increase the amount of cruelty in the world.

“Keeping Options Open”

Within the Cass report:

• Recommendation 4 directly suggests involving clinicians in decisions about social transition.
• In §12.5, Cass suggests with respect to social transition that it is “important to view it as an active intervention” rather than an expression of patient agency.
• Section §12.37 suggests clinicians advocate for the suppression of gender identity through the use of “partial rather than full transitioning” at least until “the developmental trajectory becomes clearer” (it is very unclear how the “trajectory” can become clearer if its expression is suppressed).
• Section §12.11 expresses concern that clinicians should “examine closely” the history of those who have undergone social transition for “signs of difficulty, regret or wishes to alter any aspect of the child/young person’s gender journey trajectory”.
• Section §12.16 is concerned that unsupportive parents might feel bad for being unsupportive.⁹
• Section §12.6 suggests schools should be guided by Cass’s “findings” (i.e. her opinions against supporting social transition).

And so on. None of this “aims to help people live the way they want to” but rather to challenge patients about their choices and mould them.

This needs to be viewed in the light of there being a history of abusive, coercive medical and social practices applied to trans children due to the same unblinking equation of being transgender with “harm”.

“An Altered Trajectory”

The justification for all these suggestions about “social transition” appears to simply be the prospect of an “altered trajectory” — a notion reiterated many times in the report (see §78, §83, §12.3, §12.11, §12.31, §§12.36–7, §§14.36–37, §16.21).

But altered from what? Why assume there is a favoured direction of development? Social transition could equally well be regarded as part of the unfolding of an optimal trajectory.

Indeed, Cass notes that ST is prevalent in the GIDS patient group, and that’s absolutely unsurprising: if there wasn’t at least some prior drive towards expressing gender preferences that are seen as non-normative, then it’s unlikely that patients would have been referred at all.

MPRG (Multi-Professional Review Group) observation of the frequency of social transition in GIDS patients

Concern at the prospect of an “altered trajectory” signals an opinion that being trans must be somehow a) unnatural or b) intrinsically problematic. It is literally presenting being transgender as a deviation from a “preferred” course of development.¹⁰

Disapprobation of being transgender is not, however, a legitimate argument — even if, as in §74, you deploy the dehumanizing and wildly overblown phrase “culminating in life-long medical intervention” as a descriptor, or baselessly introduce the suggestion of “gender dysphoria which might have resolved at puberty”.

The Cass Report unquestionably frames being transgender rather than cisgender as an unnatural and unwanted outcome that warrants intervention — an absolutely clear indication of cisnormative bias that is completely unconsidered.

“It Is Not Possible To Attribute Causality”

In §12.34, Cass does note that one might equally well view ST in terms of cause or effect:

But only one of these options is predicated on the notion that gender identity is malleable — that’s the idea that drives conversion therapy, and which Cass’s recommendations are built upon.

The narrative of an “altered trajectory” in Cass is tied into the notion that trans identity is artificial, the result of an extended unnatural causal chain that can be broken. Cass imagines a sequence in which social transition causes the use of puberty blockers (§12.12), which is followed by puberty blockers causing the use of hormone therapy (§14.25), culminating in “life-long medical intervention” (with the intended connotation that this is very scary).

When Cass makes recommendations intended to “break the chain” — against social transition, against puberty blockers, against hormone therapy — she is advocating to degrade the life quality of trans youth, in the expectation that this will prevent trans identity from emerging (resolving “distress”).

This idea that one can intervene in this “causal chain” in this way is pervasive in the report.¹¹ For example, in §12.36 Cass observes that “sex of rearing” is highly correlated with gender outcome — as though there was a causal link here, rather than this just reflecting that most people are cisgender rather than transgender:

If it were possible to quash trans identity simply by “rearing” children according to sex assigned at birth, there would be no trans people. Suggesting this provides support for a “cautious approach” to social transition is ludicrous.

Similarly, in §14.25 Cass specifically states that puberty blockers can’t effectively provide “time to think” because they are almost always followed by hormone treatment — as though “thinking” would naturally result in people ceasing to be trans. This is almost cartoonishly offensive.

Ockham’s razor would suggest there is a simpler explanation for the fact that social transition, puberty blockers, and hormone therapy are highly correlated. Rather than assuming there is a complex series of causal links being in play, we could instead posit a single factor of “being trans” to explain a patient’s motivation to access all of them — all of these measures are ultimately means to improve the quality of a trans person’s life by helping them “live the way they want to”, and all of these Cass argues to suppress, in the name of resolving “distress”.

The Use Of “Distress” And The Misrepresentation Of Medical Pathways In The Cass Report

How Cass Misrepresents The Use Of Puberty Blockers

The discussion of “puberty blockers” shows how far adrift from reasonableness the use of “gender-related distress” takes the Cass Report.

In §69, Cass suggests that puberty blockers are primarily used for “managing gender-related distress” and that other kinds of “psychosocial intervention” might be useful alternatives in helping to “alleviate” that distress.

This is highly disingenuous. The use of puberty blockers in trans people is not a treatment to “manage distress”; it is part of treatment required to prevent the severe later-life health issues that arise for trans people who undergo unmediated puberty.

Psychosocial interventions can’t carry out the actual function of puberty blockers: to block puberty.¹² Cass is suggesting psychological or pharmacological intervention for what is a physical condition: it’s like suggesting antidepressants as a replacement for anticancer drugs on the basis that cancer causes distress.

One cannot simply “intervene” in the way Cass suggests to make undergoing unmediated puberty comfortable for a trans person. Straightforwardly so: for them, it leads to extremely harmful consequences, wide-ranging bodily changes with irreversible effects that can only be ameliorated later in life by undergoing multiple other medical interventions of varying efficacy — some of which are excessively hard or even impossible to access via the NHS.

What the failure to use puberty blockers or hormone therapy represents for trans youth is worse outcomes (a higher cost, not just financially, but also in terms of direct detriment to patient wellbeing). It implies imposing prolonged hardship on patients as they attempt to counteract its effects.

But Cass never genuinely considers that simply allowing puberty to proceed unmediated in trans patients is not a “neutral act”.¹³ Instead, the report adopts the notion (previously mentioned) that not intervening in puberty might somehow cause trans people to become not trans, as per §§14.36-14.37.

To see this passage in a medical report about trans people is as wild as seeing an asseveration that the right kind of sexual experience might “cure” homosexuality. It is equivalent in offensiveness and a clear expression of prejudice.

Cass is apparently powered by the convinction that “you’ll grow out of it” is a viable conceptual framework for the provision of healthcare for trans youth. It isn’t. This reveals an unexamined, very queer-hostile stance.

It is utterly shameful to suggest that forcing people through unmediated puberty (or “a time of sexual fluidity and experimentation”) will cause trans identity to dissipate. One need only listen to trans adults describing their experiences of childhood, for powerful evidence that it does not. Nor does this tally with the long-standing observation that gender identity is often established very early in life, long before puberty (see §6.19).¹⁴

How Early in Life do Transgender Adults Begin to Experience Gender Dysphoria? Why This Matters for…

Among transgender children, gender identity as strong as in cisgender children, study shows

This reflects Cass’s clear belief that gender identity is malleable and that it can be shaped by medical intervention, or active medical neglect — the conversion therapist’s belief that being trans is a kind of abnormality to be “resolved” by forcing the patient back onto the “correct” gender path.

This should have no place in a review of healthcare for LGBTQ+ people.

Other hormonal treatments, generally regarded as unremarkable (for example, contraceptive pills or insulin injections) are not prescribed or proscribed on their ability to relieve existing distress but on the basis that they are effective in preventing unwanted consequences.

This is precisely what puberty blockers also achieve, particularly when followed up with hormone therapy.

It’s worth noting the special pleading that their use is “unnatural” in play when Cass states we can’t extrapolate the safety of puberty blockers in trans patients from the fact they are considered safe to use in blocking precocious puberty.¹⁵

The framing she uses is that when used in the latter group they block something “abnormal”, whereas in trans people they are blocking what is “normal”.

That is an entirely arbitrary distinction. In both uses, they are used to intervene in identical processes that would occur “naturally”. The distinction Cass draws is not a biological one: it’s a merely temporal one, about the age at which they are used.

But there isn’t anything distinct about the biological effects of the medicine upon these two groups of patients. Following Cass would lead to the absurd belief — apparently held by Wes Streeting — that the same medicine might be both safe and harmful in the same patient, ethically mutating at the point when they identify as trans.

When Cass says that blockers affect something that “should be occurring”, that is obviously begging the question when it comes to trans patients.

This accusation that a medicine is somehow “against nature” — that it is affecting what is “normal” — could be levelled at any medical treatment whatsoever. It’s an emotional reaction, not a rational complaint about the usefulness or effiacy of treatment.

Recall that trans youth will ultimately go through puberty (mediated by hormone therapy or otherwise). Puberty blockers are intended simply to delay that process for a limited period, and the timing of puberty is, in any case, subject to wide natural variation.

Viewed with these observations in mind, the catastrophising narrative that Cass puts forward about the potential effects of blockers makes no sense.

A whole lot of maybes are chained together here in an attempt to make an end-run around Gillick competence, and the key evidence that Cass cites in support (in footnote 6 of Appendix 6) is a rather breathless comment article (“a new study … marries raging hormones with the haywire prefrontal cortex”) regarding a single study on the influence of hormones at puberty of synaptic functioning in female mice: “Ovarian hormones organize the maturation of inhibitory neurotransmission in the frontal cortex at puberty onset in female mice” by Piekarski, Boivin and Wilbrecht.

That study of the effects of hormones at puberty does not in any way inform us, even tentatively, about the possible impact of temporary use of puberty blockers followed by puberty (mediated or otherwise).¹⁶

This is the perfect illustration of the double standards for evidence that are being used in reshaping trans healthcare in the NHS.

Relying on an evidence base that cannot even be dignified with the word “flimsy”, the UK has, following the publication of this report, introduced harsh restrictions on the prescription and even possession of puberty blockers, thereby radically deviating from global standards of care, and imposing gruelling physical outcomes on trans youth.

To make this decision on the sole basis of a threadbare “distress” narrative is utterly indefensible.

How Cass Misrepresents Hormone Therapy

Another example of the misuse of the notion of “gender-related distress” in Cass is in its application against the use of hormone therapy.

In §15.28 Cass openly — and outrageously — equates the ocurrence of “gender-related distress” to “longstanding mental ill health” and suggests that hormone therapy is intended primarily to address that.

Pause a moment to consider how grossly prejudiced this is: it’s another disqualifying moment of disgraceful stigmatization.

Putting that aside, the notion that “hormone treatment alone will address longstanding mental ill health” seems to be a strawman entirely of Cass’s construction. Hormone therapy is simply not intended specifically as an intervention for “longstanding mental ill health”.

If hormone therapy has effects on psychological health, that is an ancillary benefit, not the purpose of the medication: to alter the body to take it through “mediated” puberty (modulating breast growth, hair growth, and so on, by altering gene expression). Hormone therapy assists in achieving a comfortable alignment between self identity and bodily reality.

It’s perhaps unsurprising, then, that the review does find that there is evidence for the efficacy of hormone therapy in improving psychological health — but note also that this is a very different matter than “addressing longstanding mental ill health”:

Additional studies were published during the lifetime of the report which also support this:

Given that — even using Cass’s own framing — there is “suggestive evidence” of benefits but none of harm, it is impossible to reconcile the evidence Cass finds with her recommendation to exercise “extreme caution” about using hormone therapy and to call for “waiting until an individual reaches 18”.

Recommendation 8 is effectively a call to restrict the use of medical treatment on the basis of nothing but the obviously motivated reasoning of “we can only show benefits but there may be long-term harms if we look harder”.

Ultimately that argument always conceals a shell game; however hard we investigate, failure to find harms can be (and, you can be sure, will be) dismissed on the basis that we haven’t investigated enough.¹⁴

Following Recommendation 8 will ensure that all the negative effects of an unmediated puberty on trans youth will more often need to be addressed in later life, at high emotional and probably financial cost for patients. Cass entirely sidelines the fact that early hormone treatment is the least intrusive available way to achieve developmental outcomes that are beneficial for trans patients.

This is not a balanced, rational response to evidence, but the imposition of an overt and invalidating belief that trans existence is inauthentic.

Throughout the report Cass uses various rhetorical techniques that lend themselves to the facile dismissal of the evidence base for trans healthcare (particularly via the deliberate conflation of a technical and manipulable notion of the “quality” of research studies with the “strength” of evidence).

If we rewind to the start of Chapter 15, in §15.2, we see the upfront acknowledgment that for trans people, any of the putative negatives of hormone therapy are “dramatically outweighed” by the long-term benefits:

However, those obvious long-term benefits — rooted in the nature of the treatment, as discussed above — aren’t measured in the various studies of possible effects of treatment that Cass considers. By shaping her narrative around secondary items about which “no conclusions can be drawn” or for which “uncertainty remains”, any consideration of what the treatment is intended to do, and the benefits inherent in that, is made to vanish from the narrative of the report.

Here’s an example of this kind of “whataboutism”: a note that hormone therapy works as expected, followed by a stream of caveats that it might potentially affect other things, although we don’t have evidence that shows it does.

Likewise the summary of review findings in §15.25 carefully buries the lede in a welter of non-findings and careful downplaying, such as dismissing findings from “moderate quality” studies as mere “suggestive evidence”, unimportant beside the absence of documented certainty about long-term effects.¹⁷

This same rhetoric is mirrored in the structure of the chapter itself, which is largely dedicated to a winding, inconclusive and rather episodic exploration of various outcomes which might, but aren’t proven to be, affected by hormone therapy.

Note the outcomes that Cass directs her focus to, such as improved mental health or suicidality, can only be weak proxies for wellbeing. These are not direct indexes of satisfaction with the outcome of treatment, but are secondary effects that are hopelessly entangled with the stresses of social existence. Affecting them is not what the treatment is for.

Note that there is a systematic review by Baker et. al showing improved outcomes, including for quality of life (referred to in §9.27 and §14.27).

Hormone Therapy, Mental Health, and Quality of Life Among Transgender People: A Systematic Review

In §9.27 Cass emphasizes the limits of the studies, which the review itself mentions.

In §14.27 Cass entirely dismisses the review from consideration by referring to the findings of the systematic review of care pathway (which is focused on detransition, and does not consider quality of life) and the NICE review, which includes in the conclusion:

Ultimately, the chapter tails off, losing interest in hormone treatment altogether, as it embarks on an extensive but entirely tangential discussion of things Cass finds much more interesting: discussing detransition and research on long-term (negative) outcomes of treatment.

The Hypothetical Dissipation Of Trans Identity

Pogust Goodhead And The 1000 Families

In August 2022, in the wake of the interim Cass Report, the law firm Pogust Goodhead publicized the idea that “1000 families” might sue the Tavistock clinic on the basis of hypothesized regret / clinical harm.

1000 Families to Sue Tavistock Gender Service

By Jan 2024, no such clients having emerged, the narrative from Pogust Goodhead became that the hypothetical “victims” are “too scared to speak out” because of “cancel culture”. An incredible, risible, volte-face.

Cancel culture is preventing Tavistock victims from speaking out, says City lawyer

Pogust Goodhead had bought into one of the central myths of trans-hostile lobbyists: that “transition” is frequently succeeded by “regret”.

So has Cass.

Politics And Detransitioners

Stories of detransitioner regret are one of the central planks of anti-trans political campaiging¹⁸ — used in the same way that the “ex-gay” movement once provided a platform to crusade against LGBTQ+ rights.

The commonplace use of these stories for political purposes ought to prompt extreme caution — it warrants skepticism towards how these narratives have been generated and/or manipulated — which Cass simply does not exercise.

The ex-gay movement crawled so the detransition movement could run | Xtra Magazine

Former 'detransitioner' fights anti-transgender movement she once backed

The Assumption That “Regret” Drives Detransition

The notion of “regret” linked to detransition is introduced in §13 of the final Cass Report, upfront within the Summary section. This is presented as a sibling of “distress”, which may strike at any time — although this is of course taken to be an asymmetric prospect, because any kind of “regret” in trans adults linked to not transitioning in youth is never seen as worthy of consideration.

From the “Summary and Recommendations” of the Cass Report, a familiar declaration that an alternative to transition is resolving distress, plus the introduction of the idea of “regret” being commonplace.

This notion of regretful detransition is so compelling for the Cass Report that it dedicates whole sections specfically to considering it (§§15.44-15.56 and §§19.33-19.36). The report uses the term “detransition” no less than 82 times making it even more salient than “gender-related distress”.

We even see the recommendation put forward that a separate service should be established solely for the support of detransitioners:

This is farcical, given that Cass specifies that “detransition” is a term used to refer to people who have “previously medically/surgically transitioned”…

… and the data that Cass analyses (see §13.11) found less than ten such detransitioners among 3,499 GIDS patients (892 of who had been referred to endicrinology). The exact number is not available; from the wording here it appears to be greater than 2, but that’s all we can conclude.¹⁹

What’s more, we don’t know why any of these patients detransitioned. There’s no guarantee that this is down to “regret” as opposed to medical reasons or other life events. Nor do we have any indication that they would generally wish for a separate service to support detransitioning.

Given this, where does Cass think those detransition service users / Pogust Goodhead clients are going to materialize from?

The answer is that she has absolute faith that detransition simply must be a big problem in the longer term — and she grasps at all sources of support for this notion, regardless of how sketchy they are. This leads to the review promoting two main sources of myth, widely promoted by trans-hostile campaigners: one well-worn and one a modern creation.²⁰

Detransition And The 80% Figure

First, the well-worn myth. We see it put forward in §16.8, which asserts that a formal diagnosis of “gender dysphoria” might not be reliably predictive of “longstanding gender incongruence in the future”, and that it might be “resolved in other ways” than medical transition:

The same assertion that dysphoria might not be “longstanding” is made in precisely the same terms in §58, §98, and §10.72, but without supporting evidence. On what basis is this stated?

The answer appears to be in §2.6, in which Cass cites a number of studies (some of which date back to the 1980s) about the persistence of “gender incongruence” — here very loosely used to refer to groups of patients referred to specific clinics (including that of Kenneth Zucker, who also co-authored several of these studies).

These are studies that are well-known to be riddled with methodological issues; they have been repeatedly debunked over years in a multiplicity of venues. Cass does not engage with those critiques at all.

In the context of Cass’s assertions about gender dysphoria, an obvious problem is that many of these studies are simply not evaluating populations with “a formal diagnosis of gender dysphoria” in modern terms, including some of the “later” studies that Cass specifically mentions (two of which date back to 2008). The use of extremely lax criteria for what is taken as “detransition” in these studies is also notable.²¹

Debunked: No, 80% Of Trans Youth Do Not Detransition

The Cass Review Into Gender Identity Services for Children - Part 4

Detransition is a Mythology

To flatly state that a diagnosis using modern criteria is not “reliably predictive” on this basis is reckless at best, and mendacious at worst. Swathes of the Cass report, including recommendations to restrict care, are premised on the accuracy of this claim.

“Social Contagion” And Exponential Growth

The second source of myth is modern “detransition” narratives, which allege that a phenomenon of “social contagion” is creating a cohort of pseudo-transgender people: confused cisgender people endangered by the seductive glamour of transgender people, who are doomed to ultimately rue their choice to transition (i.e. “desist” or “detransition”).²²

(We can see this myth invoked in, for example, §14.34 and §16.8, in the reference to “depending on what has caused their distress or dysphoria … it may also be resolved in other ways”).

This is, fundamentally, a repackaged version of long-in-the-tooth homophobic “contagion” narratives. It is not the first time that we’ve seen a virulent strain of queerphobia being treated with utter credulity in this report. This seemingly reflects a complete ignorance of LGBTQ+ history: Cass’s lack of domain expertise is, far from being a bulwark against bias, a direct enabler of it.²³

Homosexuality as Contagion: From the Well of Loneliness to the Boy Scouts

All the Evidence Against Transgender Social Contagion

For example, Cass faithfully reproduces extensive “anecdata” that precisely mirrors the “contagion” moral panic of previous generations (for example, tales of the effect of influencers in §38, §6.41, §7.6, §8.24, §8.37, §8.47, §8.48, §8.49, §10.45, and the highly misleading characterisation of increase in patient numbers as “exponential” in §17, §35, §2.23, §3.16, §5.9, §8.26 to imply unnatural “contagion” causing changes to patient demographics).²⁴

An example of “social contagion” anecdata from the Cass Report

Note that the rise in the proportion of people identifying as transgender across generations exactly parallels the overall rise in people identifying as LGBTQ+:

LGBTQ+ Identification in U.S. Now at 7.6%

It is a clear choice to attribute demographic change relating specifically to trans people to “contagion” rather than to consider “reduced stigma” as the likely explanation:

Explaining Assigned Sex Ratio Shifts in Trans Children

The “pseudo-transgender” narrative is pseudoscience with nothing to recommend it: attempts to reify it into a syndrome called “rapid onset gender dysphoria” (ROGD) have been roundly debunked — see extensive analysis here and here — and the initial studies claiming to identify it have either been withdrawn or were subject to extensive post-publication correction due to fatal methodological flaws and obvious biases.

Correction: Parent reports of adolescents and young adults perceived to show signs of a rapid onset…

RETRACTED ARTICLE: Rapid Onset Gender Dysphoria: Parent Reports on 1655 Possible Cases

The Cass report doesn’t go so far as to cite these papers²⁵, but it does cite another methodologically flawed survey by the originator of the ROGD myth, Littman (§15.53), and similar work by Vandenbusshe²⁶ (§15.54).

Note that the systematic reviews excluded “student dissertations” (as per p3 of Appendix 2), yet Vandenbusshe’s undergraduate project research is directly cited, and regarded highly enough by Cass for a graph from it to be reproduced as Figure 37 of the report (a meaningless x-axis and a number of spelling mistakes such as “disphoria” were introduced somewhere in the process of reproduction).

What that graph shows is which pre-written narratives are chosen from Vandenbussche’s survey by a group of anonymous, self-selected and self-identified “detransitioners” — who were recruited from highly politicised online forums and social media sites; hotbeds of “anti-trans” sentiments.

As with the initial papers, this is clearly not work of the highest methodological calibre.

This is illustrative of a double standard applied throughout the whole of the Cass report: entire bodies of work on trans healthcare are dismissed from consideration by applying arbitrarily harsh cut-off points for evidential quality (e.g. the wholesale dismissal of WPATH SOC8), while any content that supports a point that Cass wishes to establish is freely cited without any regard to its evidential quality.

It is absolutely damning that Cass does not exercise due caution about pseudoscientific and/or methodologically flawed work, and frequently cites material in the course of its narrative that is either unsound or mere opinion, as though it solidly establishes fact.²⁷

The Non-Dissipation Of Trans Identity, And Implications Thereof

Despite the extensive narrative hype about hypothetical large cohorts of detransitioners, the report is in the embarrassing position of lacking good evidence that people who “regret” transition do in fact even exist in significant numbers.

Recall that Cass found less than 10 detransitioners in the GIDS data about the medical pathway:

Looking at longer term data, the systematic review also found that that of patients referred to endocrinological services, 92% or more — depending on the clinic — went on to access hormone therapy (see §§14.23–14.24), with very low rates of discontinuation:

“For masculinising/feminising hormones, six studies reported discontinuation, with very low rates (0–2 individuals) reported. High rates of continuation were also reported in the recent Dutch study, with 98% still prescribed them at follow-up (average 3.2 years for birth-registered females, 6.1 years for birth-registered males), and the UK study which found no discontinuation at 2–3 years of follow-up.”

Similarly, a recent study in Pediatrics (noted in §12.25) looked specifically at long term followup with a population of approximately 300 youths who had undergone full social transition (a broader group than those that have accessed medical treatment) and finds that “persistence” levels in this group are 97.5% after 5 years.

Gender Identity 5 Years After Social Transition

This strongly suggests that Cass’s assumption that “gender-related distress” will often resolve in “other ways” is completely erroneous — and therefore the actions she advises to take (or to neglect to take) on the basis of this belief will turn out to be harmful to the vast majority of patients.

This finding about long term “persistence”²⁸ in those who have socially transitioned is particularly notable in the light of the fact that social transition is absolutely commonplace in the UK patient population:

From the MPRG Report, Appendix 9 of the Cass Report. Note that “concern” here encompasses “affirmative” treatment, as though it should be incumbent on clinicians to challenge the patient at every turn — this is a message with conversion practice overtones also repeated multiple times by Cass. Notable here also is the extremely odd suggestion that treatment delays somehow have a causal link to social transition.

The MPRG expresses apparent disquiet that most of these patients who have socially transitioned want access to puberty blockers (Appendix 9, §1.8) but it is also not in the least bit surprising that patients that have a firm grasp on their identity would want to exercise options that allow for them to “live as they wish” — or that being unable to do so can have profoundly negative consequences.²⁹

From Appendix 9 of the Cass Report.

However, the Cass Report found that the vast majority (73%) of GIDS patients did not access puberty blockers, because they were never referred to endocrinology services.

From Appendix 8, page 14 of the Cass Report: 73% of GIDS patients were not referred to endocrinology

The strong implication here — also backed up by the paucity of detransitioners that Cass found in the data — is that access to endocrinology services for these patients has been far too tightly triaged by the NHS in the past.

An excess of caution has meant that patients that would have benefited from this treatment, and who were requesting access to it, were unable to do so, with all the consequences for long-term wellbeing already discussed.

The even more stringent “extreme caution” in prescribing that Cass recommends — along with the recent criminalization of access to puberty blockers from sources other than the NHS — is likely to drive the proportion of new patients not able to access endocrinology services towards 100%.³⁰

If the proposed clinical study of puberty blockers is never put in place — and there are substantial unresolved ethical issues relating to it — that will remain so.³¹

Extract from the WPATH AND USPATH COMMENT ON THE CASS REVIEW

Data Linkage And The 9000 Patients

The paucity of evidence for detransition within 5 years is somewhat embarrassing for the “regret” narrative. Cass therefore works a shell game, suggesting that perhaps we would find evidence of a substantial group of detransitioners if we just looked over longer timeframes.

(Maybe Pogust Goodhead can take succour from this also).

For example, see the “anecdata” of detransition after 5–10 years in §15.50, or of 10–15 years in §15.65. Likewise, the Cass-commissioned systematic review of care pathways claimed to find: “expressions of regret reported as ranging between 3.8 and 22 years after transition”.³²

Cass therefore proposed a retrospective study, analysing patient records to discover what long-term outcomes are.

This study is discussed directly following the “detransition” section of §§15.44–15.56, with the implication that it will assist in informing patent decision making, by providing information about the longer-term benefits and risks of different option (i.e. warn them of the potential for “regret”).

Outline of the scope of a retrospective study proposed by Cass

The study would link up the medical records of patients across different NHS systems, in order to find out details of the “different pathways people take and the outcomes” for the entire population that were historically referred to GIDS.

As per the research protocol:³³

The “destinations” that the research study will investigate, from the submitted research protocol document. Note the emphasis on mental health and autism diagnoses, as though too these were “destinations” for people who transition gender — again, this is indicative of the repeated conflation by Cass of trans identity with mental health issues.

Note that it won’t be possible to specifically tell who has detransitioned from linked records, only if they “appear” to have de-transitioned. That is because the data will only allow that to be inferred — but recall that the extreme looseness with which “detransition” has been inferred was a major methodological flaw in studies in studies historically. That looseness was a major factor in creating a myth of unrealistically high “desistance” rates.

This is therefore an immediate and obvious concern, raised by the adult gender identity clincs as one of multiple ethical, practical, and design issues with the study protocol.

No definition for “detranstion” is one of a large set of objections to the proposed study, which are detailed in full in Table 1 of Appendix 4 of the Cass Report

So, the study proposal does not define “detransition” or state how it will be measured: the “University of York” response to this is simply that detailed definitions “would be developed”, but this is far from reassuring.

This could easily become an exercise in gerrymandering the outcome. The UoY response states that the definition will be “in line with” the literature (which is notoriously inconsistent in the definitions it uses), clinical guidelines (without specifying which ones), and in consultation with clinic staff (again without any specifics as to who and how).

To effect data linkage across the large group of approx. 9000 GIDS patients, the proposed study would be carried out without explicit patient consent for their medical records to be used.

The linkage would even connect records across changed NHS numbers, thereby breaking a mechanism that is extremely important in protecting trans patients from being casually outed.³⁴

There’s an even more worrying privacy issue: carrying out “data linkage” for this group of patients would often require additionally circumventing mechanisms and laws specifically devised to guarantee privacy for trans people with respect to their personal medical history.

For example, the Gender Recognition Act 2004 was introduced to satisfy European Court of Human Rights rulings about rights violations.³⁵

In order to bypass that law, in 2022 the health minister at the time (Sajid Javid), introduced a statutory instrument that effectively created a loophole, explicitly naming “the purposes of the Cass review” as sufficient reason to ignore its standard provisions.

The direct and successful lobbying of a government minister to rewrite human rights protections that were specifically put in place to protect a vulnerable, marginalized group: this really does not pass the smell test for the actions of an “independent” review.

The reported stakeholder involvement (or lack of it) in the design of the study is also striking: patient input was limited to 12 individuals who were a “mix of trans and gender questioning adolescents and young adults”.

It seems that very few adults from the target population of the study were consulted, and that LGBTQ+ support organizations were involved solely as a conduit for advertising “consultation events”.

The study’s parameters are extremely concerning: the personal, intimate histories of practically anyone ever referred to GIDS could be made available to whatever researchers NHS England wishes to designate, in order to carry out a vaguely outlined project, apparently aimed at confirming the existence of a (very) hypothetical “wave” of regret in later life.

As it would not be viable to notify all former patients of a limited duration “opt-out” option to use if they objected to the use of their data, many former patients would not be aware of the study or in a position to express their wishes about the use of their personal data. Conversely, concern about data privacy could lead to a substantial proportion of the population using the opt out, making it unclear how representative any conclusions reached could possibly be.

Even though the Cass Review is complete, the statutory order made by Javid remains in force until the end of July 2027. NHS England has elected to push forward a continuation of this research, against the detailed objections of patient advocate groups³⁶ and by overriding the ethical, practical and scientific objections of gender identity clinics (as per Table 1 in Appendix 4 of the Cass Report).

The undermining of patient trust³⁷ at the scale proposed here is no less than astonishing. It is emblematic of the contemptuous, offhanded treatment trans people so often have received from the medical establishment. A contempt that Cass exhibits through and through, and which is therefore being hard-wired into the new model for NHS services.

All in the name of “distress”.

Narratives Of Distress From Trans People In The Cass Report

Intro

As we’ve already mentioned, trans people and support organisations were allowed no role in the report’s governance. This seems to have been a catastrophically bad decision.

Cass does, however, provide brief glimpses of the patient perspective on distress taken from a secondary set of narratives: the stories of patients themselves talking about the various issues they have faced in the course of treatment (or lack of treatment).

In these narratives, the intrinsic “gender-related distress” attributed to patients by Cass is nowhere to be seen; what we see instead is distress that is attributable to social stressors including medical barriers to transition.

Sources Of Trans Input To The Cass Review

The contribution of trans people to the report was through three different forums:

• Listening sessions. These are not systematically documented, nor is it entirely clear who was listened to (for example, §1.46 seems to suggest that listening sessions were conducted with anyone who contacted the review whose reports were not consistent with that from other sources). There are five quotes are pulled from listening sessions in the report, but only one is from a patient.
• A qualitative research study. The study protocol is documented here, and its findings are summarized in Appendix 3 of the Cass Report. The body of the report directly quotes only one service user — specifially, a detransitioner — from this research. Some of the summarizations are also cited.
• Focus groups. A separate summary review covers the focus group discussions. 16 quotes are pulled from this into the main report, and other elements of it are discussed in the body. There are also a series of detailed focus group reports from the support organizations that hosted the sessions, which extensively quote first-person accounts, and identify key themes.

This is the entirety of the Cass Report’s engagement with the patient voice.

Some Observations On The Design And Implementation Of The Qualitative Research Study

The qualitative research study proposed to interview 40 children and young adults.

From the Research Protocol for the qualitative study

Ultimately, only 32 participants were recruited for this study (14 young people and 18 young adults), due to recruitment difficulties.³⁸

The methodology of purposive sampling that was used by the study to ensure a “spread of characteristics” means that, far from providing a representative sample of patients, a skewed set of views was sampled.

For example, of the five categories deliberately sampled for the young adult group, four of them were defined to be groups that had not accessed medical interventions or had but subsequently considered detransition:

The group of young adults also apparently included a number of people who had simply contacted the Cass Review asking to be research subjects:

This means it is unclear not only whether the interviewees were representative of the patient population, but whether they were all part of the patient group at all. The likely motivations for individuals contacting the review team were apparently not considered.

Note that the only quote directly cited from a participant by Cass is from a detransitioner.

Appendix 3 (subtitled “Narrative accounts of gender questioning”) gives us only a glimpse of what was said in the course of the 60–90 minute interviews that were undertaken. The input of young people is summarized in slightly less than 3 pages, and likewise for young adults. What we have is therefore a harshly truncated representation of participant viewpoints.

Some Observations On The Focus Groups

The focus group questions were specifically aimed at discovering “young people’s perspectives on their journeys, including into adulthood, and their views on how services could and should be delivered in the future.”

Due to the way these were run differently by different groups, 127 “engagement episodes” were reported; the number of participants would be less than that.

These focus groups delivered a lot of specific, granular information about the issues that patients had experienced with service delivery and their detailed thoughts on improvement.

If you want a first person view of trans healthcare pathways for young people, reading these reports is highly recommended.

As per the summary report:

The focus groups took place at a time when the closure of the Gender Identity Development Service had been announced but the new regional services had yet to open. There was understandable concern about where and how care would be provided in future

These reports therefore should have been extremely valuable in informating the design of new services, to avoid repeating the delivery issues that were experienced in GIDS. However, as we will see, the proposals that Cass makes seem destined merely to exacerbate some of the key problems that these sessions identified. Others were simply ignored.

Patient Narratives Of Distress Highlighting Care Inadequacies

Within these sources, we find that expressions of distress caused by inadequate care provision are restated over and again.

These narratives of iatrogenic distress — only one facet of the social stressors that trans people experience — show us that the system often operates arbitrarily, imposing meaningless waits and reflecting ignorance about and hostility towards patient identity.

We are considering a highly marginalized population that experiences prejudice and discrimination in all areas of life: moreover, a population that has been the focus of a moral panic over a period of years.

This group should be able to at least rely on support from knowledgeable medical professionals in a service with the aim of helping them “live the way they want to”. These quotes show that often they find that access to that level of care is simply impossible — and we have already discussed the burdensome physical and psychological outcomes this failure imposes upon patients.

These voices should have been centered as part of the process of making recommendations for improvement: instead they are buried in ancillary documents and only very selectively quoted — sometimes simply to dismiss them.

In the qualitative research study:

• Excessive waiting times and a void of communication or support from NHS services are called out:

• The negative effects of lack of support for patients on the waiting list include impacts to mental health:

• Gatekeeping processes have the effect of putting lives “on hold”:

• The majority of people that were spoken to were waiting to get on medical pathways; those that had managed to access them reported a positive impact:

• Inability to access care prevents the exercise of bodily autonomy:

In the focus groups reports:

• Similar concerns were also reflected in the summary report:

• The drawn out process of diagnosis is noted as being itself a source of distress:

• We see it vividly highlighted that an inability to get medical help that has been sought causes distress:

Quote on p166 of the Cass Report

The specific focus group reports contain individual stories that illustrate these points vividly, over and over and over again. We see, endlessly reiterated:

• expressions of the stress caused by the dilatory and arbitrary nature of the pathway (refusals to refer, years long waits, being “aged out” of the service, repeated failures of communication)
• examples of capricious and hostile practices (disbelief from medical professionals, judgmental and/or arbitrary assessment processes)
• frustration that the pathway largely amounts to gatekeeping procedures that block access to medical pathways, often based on outdated concepts and stereotypes

When Cass talks of an “extensive exploration of other conditions and diagnoses” in §56, this is the reality of what she is talking about. From the trans perspective, this “exploration” is a process that acts to induce distress by impeding access to care pathways that the patient wants to access as a result of being trans.

This explanation of the logic of the care pathway as experienced by a patient doubles as a pithy summary of the ethos that the Cass Report itself embodies³⁹:

Patient quote from the Mermaids Focus Group report

Conclusions

The Use Of “Distress” As A Justification For Abusive Practices

Cass’s attribution of “distress” universally to trans people signals not just a fundamental misunderstanding of the field, but a much deeper failure: a buying-in to a hackneyed from of prejudice against LGBTQ+ people.

Specifically, the report is pervaded with the notion that to be trans (or to think one might be trans) must be inherently distressing.

This is very much at odds with the perspective of patients themselves.

From the Focus Group Summary Report

In the Cass Report, trans existence is repeatedly painted as a straightforwardly undesireable state of being that is eligible to be quashed with deliberate interventions — or deliberate neglect. The report is fundamentally an apologia for “conversion therapy” practices.

This is what “resolving distress” euphemizes throughout the report.

Conversion practices are abuses administered in the belief that sexual orientation and/or gender identity can be actively imposed on an individual — a belief in the efficacy of brutal and widely outlawed techniques which flies against all the evidence.

An assessment of the evidence on conversion therapy for sexual orientation and gender identity

The report uses narratives about “resolving” distress in an attempt to exculpate itself from this charge — what kind of monsters wouldn’t want to alleviate distress? — but the idea that “conversion” practices are ultimately compassionate and caring has long enabled forms of medicalized abuse to be imposed on trans people.

‘Pain Went Through My Whole Body’: Electroshock Conversion Therapy Victim Speaks Out

Brain,Child — The Magazine for Thinking Mothers

In the case of Cass, the idea that “stalling” transition will cause trans identity to simply dissipate is repeatedly pushed.

There are a large number of trans adults who can testify otherwise.

The report attempts to distances itself from the accusation that it supports “conversion therapy” (see §§11.4–11.7 and §§17.20–17.22). However, after publication of the final report, Cass directly warned Kemi Badenoch that a legal ban on conversion therapy would rule out the use of practices that the report advocates for. This makes those denials seem rather implausible.

The Memorandum of Understanding regarding a ban, signed for a number of years by a multiplicity of UK professional bodies — including NHS England — states that such a ban would not inhibit the provision of valid therapeutic care. So long, that is, as practitioners adopt ethical practices which are in opposition to the Cass Report’s own stance.

Evidential Double Standards

The double standards at play in the report are breathtaking: Cass demands the highest possible levels of certainty before even grudgingly acknowledging evidence in favour of what have long been routine measures in trans healthcare.

Any such acknowledgments are always accompanied by as many caveats, speculations, and invocations of what is unknown as can be mustered before being flatly ignored in the making of recommendations.

Worse, in doing so Cass isn’t really considering what these treatments are actually for — she is reviewing evidence for the existence of ancillary benefits, and taking that to provide the yardstick by which the value of treatment should be measured.

On the other hand, the report is completely cavalier in spinning wild speculations into narratives and recommendations based on the flimsiest of pretexts, with little to no caution or scrutiny.

Evidentiary standards simply don’t apply to things Cass herself wants to assert are (or might be or possibly will be or could have been or ought to have been) the case. Citations to articles that turn out to be pure speculation or mere opinion are load-bearing within the report.

Large parts of the report are completely invalid as a result.

Lack Of Domain Expertise And Unexamined Bias

Ostensibly the basis for the review being regarded as “independent”, the complete lack of domain expertise that Cass bought to the task had the consequence that she failed to identify and counter the patterns of rhetoric used in political attacks on queer people: she has instead assimilated and amplified them.

The Cass Review: independent of what?

Most fundamental of all, Cass bases the entire report on an antiquated trans-hostile conception:

“This failure to understand the purpose of trans healthcare, framing it as diagnosis, prevention and treatment of a disease, rather than supporting well-being in a minority population, flows directly into problems…”

Horton, C. (2024). The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children. International Journal of Transgender Health, 1–25.

As Cal Horton discusses at length, the review was shaped by a complete failure to examine potential sources of bias. As a result, it readily and repeatedly lends credence to the mythology of anti-trans movements and to well-worn anti-LGBTQ+ tropes. It recapitulates historical errors, and it disregards patient perspectives.

It turns out that hand picking someone without any prior experience in a highly complex field to review it is not an effective bias-avoidance strategy.⁴⁰

From the WPATH and USPATH comment on the Cass Review

This is the approach that has been used to shape trans healthcare in the UK. It is nothing less than scandalous.

The Legacy Of Cass

Cass’s recommendations reflect a vision that healthcare services for trans people should fortify arbitrary and inappropriate barriers to accessing medical care. Implementation can can only make treatment harder to access, exacerbating the problems that patients identified with the service.

In other words: far from “resolving distress”, Cass seems apt to induce it.

It can’t possibly be appropriate for an NHS gender service to remove the possibility of direct and GP referral and require referral via mental health or specialist pediatric services — because, recall once more, gender incongruence is not classified as a mental health condition.⁴¹

Yet that is precisely what the NHS has done as part of its plans for implementation following Cass:

https://www.england.nhs.uk/wp-content/uploads/2024/08/PRN01451-implementing-the-cass-review-recommendations.pdf

Mental health specialists are not specialists in transgender healthcare, and are therefore not specifically equipped to diagnose or support this patient group.

To make these services the first port of call for all patients of the CYP gender service is grossly stigmatizing.

Here, in concrete form, is the consolidation of trans healthcare as a psychiatric fief, very much against the direction of ICD-11, and driven entirely by this single review, remarkably brazen in its hostility towards trans existence.

As noted by the MPRG, patients currently have to wait up to six years to access CAMHS. Adding that to existing waiting times for gender services is clearly unworkable; but recall that Cass believes that deferring treatment will cause trans identity to dissipate, which might well make one conclude that the idea is to deliberately engineer in unworkability.

In making this move the NHS has ensured that Finland is no longer a unique international outlier…

From §19.2 of The Cass Report

… and has aligned the UK with a medical system that is mired in controversy, including accusations of patient abuse.

"Kuvaile minulle miten masturboit?" - transnuorten asema hoitojärjestelmässä on synkkä

(See https://x.com/DadTrans/status/1778896184850907490 for discussion of the later article).

Note that the Cass Review alights on Finnish standards of care as one of only two set of care guidelines that are worthy of consideration (see §45 and Chapter 9 generally). This is a conclusion which it reaches very briskly, entirely dismissing very large scale efforts to develop standards of care in just a few pages via some very creative review strategies.⁴²

This is all it takes, apparently, for the NHS to dismiss and deviate from global standards efforts.

The extensive influence that Finnish practice has had on the Cass Review is perhaps explained by the finding that Dr. Riitakerttu Katiala was one of the advisory board members for the Cass Review — despite the declaration that it was to exclude “experts” in order to avoid bias.⁴³

https://riittakerttu.fi/memberships/

Dr. Kaltiala is far from a neutral voice — a highly controversial one active within political anti-trans initiatives, in fact. She has been strongly linked to advocates for conversion therapy, including members of SPLC designated hate groups.

These controversies and connections, along with many others that Cass has to anti-trans groups, are detailed in the following articles.

Abusive Practices And Conversion Therapy Ties: The Right Latches Onto Finnish Doctor Kaltiala

The Cass Review Needs to be Thrown Out Entirely. This is Why.

The Cass Review is in no sense an “independent review”, but one with direct links to what the Southern Poverty Law Center designates as “the anti-LGBTQ+ pseudoscience network”.

Group dynamics and division of labor within the anti-LGBTQ+ pseudoscience network

Another example of the immediate impact of Cass is access to puberty blockers for new patients being immediately dismantled in the NHS, and access through providers other than the NHS being made illegal by fiat, without alternative provision first being put in place.

The potential impacts upon patients were not taken into account before implementing this ban. These hastily implemented, ill-considered measures completely undermine any confidence that future service revisions will take any notice of patient concerns or wellbeing.

For some time the NHS has not newly prescribed puberty blockers, indicating that access to PBs will be contingent on participating in a forthcoming research study. That study does not yet exist and, indeed, has not yet been designed.

It’s another form of stalling, systemically imposed and potentially affecting entire generations of trans youth.

The immiseration that will result from the implementation of Cass’s recommendations is shocking to contemplate.

Note that the patient population is one in which risk of self-harm and suicide is known to be high (see §§5.57–5.58). While Cass pays lip service to the idea that “anything that can be done to prevent future deaths is identified and acted upon” …

… it is notable that the report simply didn’t consider any of the several examples of coroner’s reports that identified NHS gender service failures as a contributing factor to patient deaths, specifically the long waiting times and lack of co-ordination between CAMHS and GIDS.⁴⁴

These inquests made headline news during the lifetime of the review.

Where is Cass’s analysis of the future prevention of deaths reports? Why wasn’t the carefully assembled evidence in these cases used to drive service redesign? Why didn’t Cass’s “strong need to understand” manifest itself?

Ultimately, then, it appears that the legacy of the Cass Report for the NHS, if it remains unchallenged, will be:

• The normalization of the practice of service reviews being carried out by non-experts in a domain, with the input of anonymous advisors, but without any patient stakeholder oversight.
• Acceptance of the use of evidential standards that are wildly inconsistent and even incoherent, in service of the acceptance of stereotypes and myths promoted by hate groups.
• The Finnification of services for trans youth, consolidating them as a psychiatric fiefdom. Aligning with the regressive and abusive notions of conversion therapists, practices such as “exploratory therapy” will be normalized, and stringent restrictions on access to medical pathways will be imposed.
• The UK being pushed out of alignment with global practice and ICD-11 standards.
• An escalation of iatrogenic distress in transgender youth, caused by the imposition of additional layers of bureaucracy, and many more stigmatizing “evaluative” hoops to jump through to access care, all arbitrarily introduced in a field of healthcare long notorious for excessive gatekeeping.
• A bad faith rhetorical framing of trans people as ubiquitously suffering from “distress” that will be carried over into a review of adult “gender dysphoria” services — shaped by “concerns” put forward by Hilary Cass.⁴⁵

This whole abject farce and its aftermath is absolutely shameful for the NHS. The necessity to put aside the review and reconsider is urgent.

The Right Honourable The Baroness Cass OBE FRCN FRCGP.

Footnotes

[1]

Forty six times without the hyphen, plus seven times with.

[2]

Both diagnoses are used in the NHS, and the terms are in practice used interchangeably, as per this BMA guidance on gender incongruence. The Cass Report also refers repeatedly to both “dysphoria/incongruence” and “incongruence/dysphoria”.

The “gender dysphoria” diagnosis is more commonly referred to. Partly that’s because it is older, and therefore more widely used in the field. But it’s also the case that a “gender dysphoria” diagnosis is still entangled with legal recognition of trans identity in UK and it is therefore pragmatic for this diagnosis to be retained.

The legal status of “gender dysphoria” is part of a medicalized model of identity recognition for trans people, an approach that is increasingly being rejected by nations with a progressive stance towards LGBTQ+ rights.

Germany: Landmark Vote for Trans Rights Law

The term is viewed by many as stigmatizing, and therefore moves in the NHS that emphasize the term (e.g renaming “gender identity clinics” to “gender dysphoria clinics”) are to be deprecated.

[3]

The NHS still largely uses the older ICD-10 standard, but is in the process of broadly adopting ICD-11.

For information: Preparations for the implementation of ICD-11 - NHS England Digital

For example, ICD-11 implementation with respect to mental, behavioural and neurodevelopmental disorders is already underway in Scotland.

Mental health: implementing the International Classification of Diseases 11th edition

DSM-5 is used as a de facto diagnostic standard within some services.

[4]

We aren’t going to examine Cass’s proposals regarding psychosocial interventions in detail. Gideon Meyerowitz-Katz has a good overview as part of his multi-part analysis of the Cass report:

The Cass Review Into Gender Identity Services For Children - Part 7

To cut a long story short, here is a brief quote from that article:

This is one of the most scientifically problematic parts of the review, and it really undermines the entire rationale of the document … the only therapies recommended by the Cass review are supported by the lowest-quality evidence in the entire document.

Note also this article by FAIR, containing similar critique:

Media Boosted Anti-Trans Movement With Credulous Coverage of 'Cass Review'

This also quotes Dan Karasic, a psychiatrist with 30 years experience in treating gender dysphoria, on Cass — zero years experience — casually recommending the use of pharmacological treatment:

There is absolutely no evidence to support Dr. Cass’s suggestion to substitute antidepressants for puberty blockers. It’s telling that Cass suggests an intervention utterly devoid of any evidence — antidepressants for gender dysphoria — over established treatments.

Both this and the report’s similar suggestion with respect to contraceptives are literally proposed on the basis of nothing more than a hunch.

[5]

In this, Cass is very much following in the (goose)steps of those who have gone before:

A Half-Century of Conflict Over Attempts to 'Cure' Gay People

[6]

For example, sections 1(h), 1(i), 2(a), 2(d), 2(f) and 4 of the community sourced TransActual definition of transphobia:

Transphobia

[7]

For example, Cass had sole authority to appoint members of an advisory group (see here), under the following terms:

‘Members of The Advisory Group will be independent of NHS England, and of providers of gender dysphoria services, and of any organisation or association that could reasonably be regarded as having a significant interest in the outcome of the process of review.‘

It has been revealed that one of the members was Dr. Riittakerttu Kaltiala, a concerning choice as a highly controversial figure who certainly does not meet that requirement. (We will return to this point in the conclusion).

It is unclear who the other members were. As the membership of the advisory group has never been made public, it is impossible to verify if conditions imposed to hedge against bias in that group were met, making the stipulation completely worthless.

[8]

As already noted, the narrative that trans identity “dissipates” is a precise recapitulation of homophobic myths commonly recited 20+ years ago. A similar assertion with respect to being gay looks absurd to most today, but the idea remains beloved of conversion therapists.

Here is that mythology expressed by a notorious anti-gay campaigner:

The Boston Globe (Boston, MA) 2003–05–25 — taken from this thread of clippings that show how transphobia recycles homophobia https://x.com/ImplausibleGrrl/status/1110869581038415874

Today’s academically-credentialed anti-trans campaigners are quite happy to recite the same talking points as yesterday’s academically-credentialed homophobes.

[9]

It is commonplace for queer people to experience abuse from family members, including parents.

LGBT+ Experiences of Abuse from Family Members

Supportive parents play a key role in the wellbeing of LGBTQ+ youth.

Family Acceptance Saves Lives

In the light of this, it is particularly unpalatable for Cass to align with the “concerns” of unsupportive parents worried about “their child being socially transitioned” — note the language implying that this is something that is being imposed upon them from without.

[10]

This is a manifestation of the same bias that drives investigations into the aetiology of sexual orientation in search of “reasons” for homosexuality, while entirely neglecting to investigate “reasons” for heterosexuality.

Straight: The Surprisingly Short History of Heterosexuality · OutHistory

That is, bias that stems from assumptions around what is “natural” or “unnatural”. In those biased explorations of homosexuality, a fascination with originating mechanisms is indicative of an interest in finding ways to interfere with them, in the belief that homosexuality is “unnatural”.

The Cass Report manifests this same bias very strongly, spending the whole of Chapter 8 fruitlessly absorbed by the same kind of wild goose chase, speculating about the aetiology of trans identity as though this will give the key to a “cure”.

[11]

This is also something we see in the MPRG report (in Appendix 9):

From the MPRG Report, Appendix 9 of the Cass Report.

The MPRG suggestion that treatment delays somehow have a causal link to social transition is extremely odd.

Note that the “concern” here encompasses an “affirmative approach”, as though it should be incumbent on all comers to challenge the patient with respect to their identity at every turn. This is a message with clear conversion practice overtones which is repeated multiple times by Cass especially with respect to clinicians.

[12]

This is a function which Cass notes, in passing, that puberty blockers undoubtedly exert and that “has never been at issue”:

In other words, we know that puberty blockers are effective for their intended purpose:

The phrasing here that puberty blockers are a factor in “better cosmetic outcome” is a way of dismissing its role in preventing distressing bodily changes that require extensive medical intervention to imperfectly reverse in later life. This positions trans experiences as being fundamentally a matter of superficiality that is unimportant: something which has no place in a review of transgender healthcare.

As per WPATH SOC 8:

Gender-affirming interventions are based on decades of clinical experience and research; therefore, they are not consiered experimental, cosmetic, or for the mere convenience of a patient.

[13]

See: de Vries, A. L. C., Richards, C., Tishelman, A. C., Motmans, J., Hannema, S. E., Green, J., & Rosenthal, S. M. (2021). Bell v Tavistock and Portman NHS Foundation Trust [2020] EWHC 3274: Weighing current knowledge and uncertainties in decisions about gender-related treatment for transgender adolescents. International Journal of Transgender Health, 22(3), 217–224. https://doi.org/10.1080/26895269.2021.1904330

(Note that the ruling discussed in this paper was overturned on appeal. The halt to prescription of puberty blockers that NHS England had imposed in the interim was not).

[14]

In §6.20 Cass suggests that “modern childhood experiences are different”, an idea that she explores in Chapter 7 which pretty much blames the internet for the existence of trans people.

[15]

Cass claims that puberty blockers for precocious puberty ”have undergone extensive testing” and “have met strict safety requirements” – yet there are no citations in the report that support this assertion.

What safety requirements? How was this ascertained?

These are claims that have been directly repeated by Wes Streeting in support of legal restrictions on the possession of puberty blockers.

Tweet by Streeting, 11:40am on July 14 2024

Claims apparently made by Cass with zero evidential support are directly being taken up by government ministers and used to form policy.

That is completely insupportable.

[16]

In fact, the entire literature about the gendered effects of hormones on human brain development is built on what can charitably be described as fairly shaky foundations.

Brain Storm - Harvard University Press

Cass cites this literature uncritically (e.g. §§6.21–6.31, §6.42) which is a very striking choice in a review of transgender healthcare.

[17]

Here’s another example of the approach Cass takes towards evidence, from Chapter 14 on puberty blockers.

In §14.27, Cass notes a good quality study relating to improvements in mental health measurements was found by the systematic review.

From 14.27

By the time we reach the summary in §14.46, the systematic review is said to have only found studies of poor quality.

Abracadabra.

[18]

This article (unfortunately paywalled) details how a handful of “celebrity” detransitioners are flown around the US to testify in multiple political hearings geared towards banning transgender healthcare at the state level:

How a Few Stories of Regret Fuel the Push to Restrict Gender Transition Care (Published 2023)

The article is discussed here:

The NYT Asks: Why Are There So Few Detrans Activists? - Assigned

[19]

The low rates of detransition seen here match with previous analysis of 2016–17 data reported in “Detransition rates in a national UK Gender Identity Clinic” by Davies, McIntyrem and Rypma.

[20]

Cass also apparently invents a third myth out of this air:

The term “trans” has not had a radical reinvention during the lifetime of the review. This is, quite frankly, a very weird assertion.

It would be interesting to learn what Cass believes “the implications for conceptualisations of detransition” are, but that remains obscure.

[21]

Here’s an example of the looseness of what is meant by “detransition”.

In §15.49 Cass cites a study that found a 7% rate of detransition in adult patients of NHS gender identity clinics, which might suggest a more substantial rate of regret later in life:

However, if we dig into that study, we find that “regret” was only found in two cases:

The nature of that regret is unspecified — we can’t tell if this reflects choices regretted, or regret that stems from that quality of care provided.

In fact, the report concludes by suggesting that a coarse category of “detransition” is in itself unhelpful, as it doesn’t capture the actual nuanced experiences of patients, for whom the assumptions of a simple “binary” transition may not always be a perfect match:

Would all those patients describe themselves as “detransitioners”? Given this caveat, it seems highly doubtful. The notion of “detransition” here is one imposed on patients retrospectively by the authors of the study.

[22]

This is the worldview that is pushed in an infamous conspiratorial book called “Irreversible Damage”.

Abigail Shrier's Irreversible Damage: A Wealth of Irreversible Misinformation | Science-Based…

As per the above review:

In brief, Shrier’s book is a fear-filled screed, full of misinformation, biological and medical inaccuracies, logical fallacies, and propaganda

Cass has denied an allegation (since withdrawn) that she recommended that colleagues read this book.

[23]

Recent queer history is entangled with recurrent reconceptualizations. What might appear as “contagion” is often just the opening up of new possibilities.

https://www.bostonreview.net/articles/whos-afraid-of-social-contagion/

[24]

Although Cass spends the entirety of Chapter 5 talking about changes to patient demographics, the MPRG report (Appendix 9) on cases referred for endocrine treatment since 2021 notes that a demographic change has not been reflected in the cases that they have reviewed:

This divergence is not addressed in the report, but it presumably reflects the reported ages of referral in Figure 12 of the report: the waiting lists mean that patients referred at 15–16 would presumably age out of the service prior to referral to endocrine services.

In the light of this, it is striking that so much emphasis is laid on demographic change in the report.

[25]

Littman and Vandenbussche are certainly not the only questionable citations that Cass relies on. For example:

• In §2.18 the report directly cites “Thoughts On Things And Stuff”, a YouTube channel that links to an extensive collection of transphobic propaganda.
• In §7.20, it cites Nadrowski (2023) who suggests that exploration with gender-questioning youth should include consideration of their engagement with pornographic content. The sole basis for this is her opinion that it would be a good idea.
• Cass cites a paper and a letter by Michael Biggs, a sociology professor who has been exposed as using the fake identity “Henry Wimbush” to post abusive transphobia online. Biggs is an advisor to SEGM, a group named by the Southern Poverty Law Center as a hub of the anti-LGBTQ+ pseudoscience network (see this detailed analysis).
• For some reason it cites the Cambridge Advanced Learner’s Dictionary & Thesaurus to define “confounder” and “GP”.

[26]

Vandenbussche, at the time an undergraduate in the Faculty of Society and Economics at Rhine-Waal University, recruited subjects for her study from anonymous online forums such as r/detrans and a site for detransitioners (PostTrans) that she herself set up, as a detransitioner.

[27]

An observation also made in An Evidence-Based Critique of “The Cass Review” on Gender-affirming Care for Adolescent Gender Dysphoria

Unfortunately, the Review repeatedly misuses data and violates its own evidentiary standards by resting many conclusions on speculation. Many of its statements and the conduct of the York SRs reveal profound misunderstandings of the evidence base and the clinical issues at hand. The Review also subverts widely accepted processes for development of clinical recommendations and repeats spurious, debunked claims about transgender identity and gender dysphoria. These errors conflict with well-established norms of clinical research and evidence-based healthcare. Further, these errors raise serious concern about the scientific integrity of critical elements of the report’s process and recommendations

[28]

The use of this term “persistence” itself is an interesting framing, as it seems to connotate a conscious, dogged perseverance against expectation, suggesting that “dissipation” is the expected outcome.

[29]

We glimpse some of the negative outcomes in §§12.12–12.13:

Note the deprecation of “living in stealth” from the MPRG, as though queer people should be expected to emblazon their personal histories for public consumption.

Would the MPRG, I wonder, likewise characterize gay people not publicizing their sexual orientation as “withholding personal information” about their “sex-based experiences”. Or is that kind of casual homophobia frowned upon in their professional circles?

Perhaps it’s not “living in stealth” that causes stress and anxiety: an inability to access medical care that affirms you in your identity, the lack of which forcibly outs you, might have that effect. Especially if it comes inevitably coupled with other forms of social intolerance.

[30]

A ban put in place through the use of emergency powers, and extended by the same means — without any meaningful patient consultation having occurred.

But there is no genuine emergency here, just a manufactured panic.

Puberty blockers temporary ban extended

[31]

One must question such a study being overseen by Cass when she herself regards “persistence” as a symptom of a problem. In §14.25

If trans people are already being accurately diagnosed before puberty blockers are prescribed, then “persistence” is exactly what you would expect to see.

[32]

If one follows up the citations for this claim, it is hard to see how this paper on Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery in Sweden supports the claims about detransition timeframes made in the review.

[33]

Interestingly, this is different from the RQs for the datalink study mentioned in the Cass Review’s research programme page, which don’t include mention research into detransition rates.

[34]

Cass’s Recommendation 28 is made apparently in chagrin that fundamental privacy rights apply to children as well as adults.

[35]

The Gender Recognition Act of 2004 was introduced by the UK government to put into effect rulings by the European Court of Human Rights. It is intended to guarantee the fundamental human right of privacy to trans people.

The ruling in Goodwin vs. United Kingdom:

https://hudoc.echr.coe.int/eng?i=001-60596

The UK response in reference to implementing the ruling:

https://hudoc.echr.coe.int/eng#{%22itemid%22:[%22001-106990%22]}

[36]

Here, by the way, is the response of the Health Research Agency to those concerns:

Our response to concerns raised about the ‘Outcomes for children referred to the Gender Identity…

It’s amazing that the vagueness of “the responses gave us the assurance we needed” is deemed sufficiently mollifying for those raising concerns.

[37]

The patient consultation process apparently involved asking 12 trans and gender questioning adolescents and young adults (as per Appendix 4) about use of their data in this study and found them “generally supportive”.

From p3. of Appendix 4 in the Cass Report

This seems less than robust.

[38]

Why would the research team encounter recruitment difficulties?

First, bear in mind that the trans community is aware of recurrent entrapment and/or subsequent hostile abuse of trans people being interviewed by groups that turn out to be fronts for anti-trans sentiment.

Second, unaddressed scepticism was engendered online by revelations about the governance setup of the Cass Review and the online Twitter profile of Cass herself — which indicated she followed multiple trans-hostile groups.

[39]

Another of the Catch-22 aspects of trans healthcare is that the intractability of mental illness induced by denying access to healthcare interventions can be used as an excuse to deny future access to those interventions.

For example, the MPRG report notes that mental health issues in the patient population are most often represented in the form of social anxiety.

MPRG observation from Appendix 9 of the Cass Report

It is a nonsense to think that mental health issues of this kind could be “dealt with” prior to / separately from issues relating to gender and the process of transition: by nature these aspects of health are entwined with the social, and will directly impact on social anxiety and other issues.

As a parent expresses it in a listening session, mental health issues can arise “because of how society and institutions treat them”.

That observation was also captured by the qualitative research study:

From the Summary of the Qualitative Research Study

Here we glimpse the overlap between “distress” and “impairment” as per the diagnostic criteria for gender dysphoria.

[40]

Cass was hand-picked to run the review. No other person was considered; there was no shortlist or process involved, as this freedom of information request revealed.

Kemi Badenoch specifically stated that the Cass Review was commissioned as part of a deliberate strategy of the government to place “gender-critical” (i.e. transphobic) people in key positions within equalities and health.

Tweet by Badenoch, 7.32pm, June 8 2024

The process was tainted from the start, and the framing of the report simply reflects this.

[41]

Of course some trans people would benefit from improved access to mental health support on the NHS. So would many groups.

But the fact of CAMHS referal operating as a mechanism to inappropriately “stall” access to trans-specific healthcare interventions is one of the issues repeatedly called out by the focus groups — feedback from patients that was completely ignored.

[42]

The appraisal of international standards for healthcare in Cass is very brisk, seven pages. And the conclusion is that only two are worth adopting in practice — the Finnish and Swedish guidelines. This is based on the results of a quality analysis commissioned by Cass.

The analysis uses an instrument called AGREE II which rates guidelines across six domains. It’s basically a survey with a number of questions using 7 point scales. Three people filled this out, and that gives us the ratings.

Straight out of the gate in §9.13, Cass tells us that rigor is the most important (“bedrock”) of those domains. In fact, so important — alongside editorial independence — that §9.14 suggests that a low score for rigor rules out a guideline for recommendation for use, even if otherwise it scores highly on AGREE II.

By introducing an arbitrary cut-off point for rigor alone, Cass excludes from consideration all but two of the 23 guidelines. But a cut-off point is not part of the AGREE II manual. This is an arbitrary imposition by Cass, and this isn’t a reasonable outcome.

Why is editorial independence — another key domain according to the study Cass cites — completely ignored here? The Finnish study that makes the grade here has an editorial independence score of zero.

If we simply move the cut off point to 30%, the point at which they become “red banded” in the table, we then have six guidelines that make the grade. And, interestingly, the AGREE II instrument includes an appraisal of overall quality. The Cass report does not show this, but it is buried in the Taylor study, under an “supplemental material” link, that pops up a table showing the overall recommendations of the individual reviewers.

We see there that the Endocrine Society 2017 guidelines get an overall score of 4 from all reviewers, and that only one of the three reviewers recommends against their use. The Endocrine Society 2017 guidelines are also the only ones that get a “green” score for editorial independence in this appraisal. In rigor, they get 44 — only just below the cut off point Cass arbitrarily introduces.

Gender Dysphoria/Gender Incongruence Guideline Resources

The Endocrine Society guidelines do not, of course, fit with the recommendations that Cass makes — but the introduction of arbitrary cut-off points to exclude guidelines from consideration entirely means that Cass never even has to consider them.

It may seem odd that the comprehensive work of WPATH, the World Professional Association for Transgender Health to produce standards of care, undertaken over a period of years with the contribution of more than a hundred experts in the field collaborating across international line is, in the estimation of Cass, outpunched by Finnish guidelines underpinned by a single review paper, with zero editorial independence.

It is, rather.

[43]

Note that Dr. Kaltiala’s research is cited directly in a couple of places in the Cass Review, but nowhere is there any declaration of potential conflicts of interest. (See also Footnote 7).

[44]

Some Prevention of future deaths reports are linked below.

The factors of concern that coroners identified included extremely long waiting times for gender healthcare services, together with a lack of suitable support or knowledge from CAMHS.

Sophie Williams: Prevention of future deaths report — Courts and Tribunals Judiciary

Amarnih Lewis-Daniel: Prevention of future deaths report — Courts and Tribunals Judiciary

Alice Litman: Prevention of future deaths report — Courts and Tribunals Judiciary

Jason Pulman: Prevention of future deaths report — Courts and Tribunals Judiciary

[45]

The review of adult services, following on from Cass, is already shaped by intial “concerns” that Cass raised in a letter.

There are some familiar patterns in it.

Recall that the Cass Review basically regards transitioning in young people as indicative/causative of being not mentally competent. The same patronizing attitude is directed towards adults by Cass directly asserting that patients do not have the “cognitive ability” to understand treatment outcomes, perhaps (she speculates wildly) because of the influence of “social media videos”…

… which “in some instances” meant patients were dissatisfied.

Let’s pause and consider that this is based — as is every “concern” Cass raises here — on anecdote alone.

What if we were to look at actual data about dissatisfaction rates?

Here, for example, is a paper in the American Journal of Surgery literally called A systematic review of patient regret after surgery - A common phenomenon in many specialties but rare within gender-affirmation surgery. The last sentence of the abstract:

When comparing regret after GAS to regret after other surgeries and major life decisions, the percentage of patients experiencing regret is extremely low.

Here is a systematic review and meta-analysis:

Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence

This also finds a regret rate of less than 1%.

Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS.

In sort, it is hard to find any surgical procedure that has a higher satisfaction rate.

Apart from being grossly insulting, Cass is raising “concerns” that appear to be completely adrift from reality. We are seeing “issues” with care are being reified solely on the basis of conversations that Cass has had with like-minded clinicians — which is of course extremely concerning in the light of the systematic biases we’ve already seen in the review.

Other of Cass’s concerns explicitly include that co-occurring mental health issues should be addressed before prescribing hormones — again, this should seem familiar, an approach which would impose arbitrary barriers to accessing care, just as was done in youth services.

In fact, Cass appears to think that patient complaints notwithstanding, “evaluation” should be allowed to be as dilatory as a clinician wishes. This is obviously the perspective of “exploratory” (conversion) therapists who believe identity might “dissipate”.

Cass also notes “concern” at the possibility of proceeding straightforwardly, even if hormone therapy aligns with patient wishes and there are no contraindications. Because Cass believes it’s not “up to patients to make their own mistakes” — which is one again in total contradiction to the aim of gender dysphoria care “to help people live the way they want to”. Clinicians can’t dictate what your gender is to you.

(By the way, current waiting times for traditional GICs — which are set to get radically worse — mean someone being put on hormones has already been on a waiting list for a minimum of 5–6 years).

Checking the scope of the review of NHS adult gender dysphoria clinics reveals that such concerns have been very much taken on board, with the review including this action:

It would not be surprising to see the same “evidence-based” gameplay that Cass used rerun with respect to adult services, in which the evidence reviewed with respect to hormones ignores the purpose of the treatment entirely in order to dismiss its validity.

There is much else that bodes ill that could be drawn from these initial stirrings of the adult review. It is more than likely that we will see similar rhetoric, similar framings, and similar failings from the adult service review: Cass has already laid the groundwork.