The original can be found here.
Dr Max Davie - Consultant Paediatrician and former Education Lead for the new child and adolescent gender services at Great Ormond Street Hospital (GOSH).
Dr Lorna Hobbs - Clinical Psychologist and former clinician at the Gender Identity Development Service (GIDS) / former Education Lead for the new child and adolescent gender services at Great Ormond Street Hospital (GOSH).
Note from Max Davie: I have co-authored this post with my colleague Dr Lorna Hobbs. We have been dismayed at the uncritical way in which the deeply flawed Cass report has been accepted both professionally and in the wider political conversation. We wanted an alternative view, from experienced clinicians, to be out there in the public conversation. We have chosen to publish this on a blog, rather than in a journal or other publication, so that we can publish in a timely way and maximise access for people who might find our writing helpful.
The Cass review - the most comprehensive review of gender-related care for children and adolescents to date[1] - was published four months ago now, and its impact on the world of youth gender healthcare is becoming clearer, with the review findings already being used to justify a legal ban on any new puberty-pausing prescriptions for gender diverse young people, under 18, in England, Scotland and Wales (outside of a research protocol); and further afield, in the US, it is being used in at least ten states to support legal bans on gender-affirming care for young people (McNamara et al., 2024[2]). At the same time, a new UK government is taking office, with an opportunity to take their own perspective on the document.
The Cass review has provoked an enormous amount of comment for a piece of healthcare literature. Directly after its publication, the mainstream media narrative was overwhelmingly positive; the review was presented as an authoritative, objective opinion on a divisive and complex area of healthcare. However, over time, critiques have appeared from clinicians and researchers, many with experience in child and adolescent and adult gender care, which have cast the report in a different light[3]. What we feel has been missing is the perspective of those involved in the transformation of the clinical approach dictated by the review.
We were both involved, to some extent, in the transition from the old Gender Identity Development Service (GIDS) at the Tavistock, to the first new regional service housed by Great Ormond Street Hospital (GOSH). We therefore would like to take the opportunity to offer our thoughts on the document: how it could be used to further the cause of trans healthcare, and how we fear it will contribute to the rise in outdated and harmful attitudes and practices towards gender diverse young people.
In committing these thoughts to print, we are not seeking to settle scores, or dismiss the work of the Cass review team. What we are aiming for is to convince the reader to approach the Cass review in a critical way, and to see it as a product of a particular world view and set of beliefs, rather than an authoritative objective overview.
We will begin by outlining the elements of the review that we think are most helpful.
The good
Cass does get a number of things right- here are the main ones.
- Systematic reviews. These were commissioned via the University of York and are, within the parameters laid down, done comprehensively and competently. There are justifiable technical critiques made, for instance by Gideon Mayerowitz-Katz, 2024[4]. MacNamara et al., 2024 make a more direct criticism of the potential bias in the reviews, citing omission of key positive outcomes, failure to consider harms of inaction, and a lack of consideration of patient preferences and values. But with these caveats, the reviews of medication are a valid survey, and rightly emphasise the lack of certainty about both the benefits and harms of medical transition.
- Holistic assessment. By giving a clear framework, the review ensures that all future assessments will be ‘holistic, comprehensive, individualised and include a co-developed treatment plan for gender issues that may involve any combination of social, psychological and physical interventions’. We might point out that the ‘old’ GIDS assessments already covered all but a few of the assessment areas proposed by the review, and that such a lengthy list of assessment requirements tends to prioritise the ticking of boxes over genuine exploration. However, particularly in the current climate, it is a good idea to have an auditable framework to refer to.
- Restructuring and integrating the service. At the more specialist end, the review makes a sensible if obvious suggestion to unite the mental health and medical arms of the regional services within one team and one governance structure. The integration of local and regional services is also imagined by the review. While nobody would deny that integrated care is a worthy goal, a sceptic may wonder where the money for this quite complex structure is going to come from, but it is a laudable vision.
- GID service audit. Two important findings made by the Cass team, that received little attention in the review, came from their audit of the GID service[5]. The media narrative often claims that medical intervention was given to gender diverse young people too often and too quickly. However, the data from the Cass audit study of the GID service quite clearly refutes these claims. In data the Cass team collected from 3306 GIDS patient records[6] 893 (27%) received puberty-pausing medication, gender affirming hormones (i.e. oestrogen or testosterone) or both, and 2413 (73%) received no medical intervention whatsoever. The data from the audit also indicated that it actually took many years for young people to access medical intervention; with most people waiting over 2 years on an initial waiting list[7]. Once young people reached the top of the waiting list, they attended an average of 6.7 assessment appointments before the Bell vs Tavistock judicial review (JR), and an average of 15.8 appointments after the case, often with several months in between each appointment. Once a referral to endocrinology had been made, young people waited several more months to see an endocrinologist, and several more months to start treatment - a total waiting time that ranged from 4-7 years Two reasons why these findings are so important are:
1) The claims of ‘too often’ and ‘too quickly’ are two (entirely untrue) reasons commentators cite for banning medical interventions for gender diverse young people in the first place.
2) They may help provide an explanation as to why the rates of detransition of people who went through the GID service are in-fact very low (not high, as the media and political narratives claim).
The Bad
Gideon Mayerowitz-Katz’s eight-post marathon[8] is the best source for documentation of the factual errors made by the review, so we will just offer a summary here.
- Minimising benefits of medical intervention. The Cass team consistently emphasises that medical transition has “remarkably weak evidence", and that it was introduced on the basis of a single study. This is untrue. The systematic reviews of medication found over 100 studies. These reviews do emphasise that most of the evidence is ‘low quality’, but it is important to understand what this actually means. From an academic perspective this means that there is low certainty that any of the benefits shown were caused by the treatment rather than just an association. The Cass review is highly misleading in its reporting of these results. For instance, the vast majority of the data on mental health and gender affirming hormones suggests a benefit, often quite significant. Yet the review will only say that there is insufficient evidence, which could mean anything, unless the reader digs into the detail of the systematic review. Furthermore, the review team do not describe any of the observed positive outcomes of gender-affirming medical intervention (e.g. improved body satisfaction, congruency of appearance, improved quality of life, mental health and psychosocial functioning, and reduced suicidality). We are not saying that no more research is needed or that the benefits of medical intervention are certain for an individual, but the review team clearly minimise the potential benefits of puberty-pausing and gender affirming treatments throughout the review, and the consequences of this has been a legal ban on puberty-pausing medication that will, in our view, cause significant harm to trans young people[9].
- Ignoring potential harms of not offering treatment. The Cass team do not mention any of the potential harms caused by not offering treatment, of which there are many - the development of permanent secondary sex characteristics that are not congruent with a person’s gender identity (e.g. a deepening voice, facial hair growth, breast tissue growth to name a few) can cause high levels of distress to many gender-diverse youth. This development may mean they no longer ‘pass’ in public as the gender they identify as, leaving them more vulnerable to discrimination and violence. In adulthood, many will choose to have expensive and invasive procedures/surgeries to ‘undo’ the unwanted and distressing pubertal changes, but this will not undo the pain caused by not being able to access gender-affirming treatment in adolescence in the first place. If the review team had made greater efforts to seek the views of people who had and had not been able to access puberty-pausing medication, perhaps these outcomes would have been harder to ignore.
- Inappropriate use of systematic review for non-medical gender-affirming interventions. Social transition can mean something as simple as changing one’s pronouns or name, or dressing differently. But Cass decided early in the process, on the basis of an unclear rationale, that social transition was an intervention, comparable to medication, and ordered a systematic review. This was inappropriate: systematic reviews are appropriate when you are looking at a discrete intervention with a measurable direct consequence in a controlled environment. Social transition is none of these things (and actually medical transition falls short of many of these, which is one reason why the systematic reviews do not show more benefit). So the systematic review could find almost nothing of use to it, because it was the wrong tool[10]. The problem is that if you take an even slightly broader view, using a minority stress lens to look at the experience of gender-diverse youth, a much clearer picture emerges of the significant benefits of social transition[11]. Many of the pre-pubertal gender diverse young people seen at the GID service were doing well in many or all areas of their lives, post social transition, and it was often only when puberty started that distress levels increased. However the systematic review hammer was inappropriately applied to this non-nail, and thus came to the inevitable conclusion that social transition is not ‘of benefit’. It was also found to not cause any harm, yet it appears that Cass does not need actual evidence to cite potential harm, as we will see in the next section.
- Exaggeration of harms of transition (social or medical): while putting any claim for benefit under the most exacting of microscopes, the Cass team is extraordinarily casual when it comes to amplifying potential harms. We will offer two examples, but again, Mayerowitz-Katz has covered this very well[12]: When it comes to social transition, vague worries that an early social transition may encourage the child to be trans and therefore have less optimal outcomes, are taken at face value, rather than being interrogated for the obvious (harmful) assumption underlying them that a trans identity is somehow less desirable than a cis identity.[13] In medical transition, vague and thus-far unsubstantiated worries about neurodevelopmental outcomes in young people who use puberty-pausing medication, are also used as a strong argument to avoid medical intervention[14]. A further speculation by the Cass team was that social transition and puberty-pausing medication could cause harm by putting young people on a medical pathway and changing the trajectory of their psychosexual and gender identity development. No data is provided to support this concern. There is data to show that many young people who take puberty-pausing medication do then go on to take gender affirming hormones, but it’s not clear to us why such continuity of care is seen by Cass as a negative outcome. It is also very likely that this outcome is a result of gender-diverse young people being triaged appropriately, with those that are indeed transgender being referred onto a medical pathway if that was something requested by the young person and family. It is important to note that the prescription of puberty-pausing medication is only being banned in the UK for gender-diverse youth - it continues to be prescribed to cis gender young people for conditions such as precocious puberty, and for young people with intersex conditions, without any cause for concern (for information on how youth gender-care is treated differently to other areas of paediatric medicine see Mc Namara et al., 2024).
- Moving the goal posts to favour psychological therapies. One of the stated aims of the review was to compare medical and psychological management of gender dysphoria. So, alongside the systematic reviews for medical intervention is another for psychosocial therapies (see Appendix 2 of the Cass review). The data was scant and mostly low quality. Strangely, the review team used a completely different quality assessment measure in the review of psychological therapies compared to the other reviews, and they did not exclude low quality studies, as they did in the other reviews (a significant protocol deviation). No rationale was given for these decisions, which made side-by-side comparison of the two intervention types meaningless. Furthermore, the review found no data for interventions aimed at improving gender dysphoria, but none of these factors deterred the review team from concluding that psychological therapies were preferable to medical intervention, which is just not supported by the data in the review. It is important to emphasise here that we are not saying that young people should not receive psychological therapy for any co-occurring difficulties or that they should not be given the opportunity to explore their gender, in a client-led and patient-centred way, with support of gender specialists; they absolutely should, and this is set out clearly in the WPATH standards of care guidelines (version 8) for any young person accessing, or wishing to access, medical intervention[15].
- Incorrect claims that most young people either ‘grow out of’ gender dysphoria or most of those who do transition later detransition. The review cites old literature (the most recent of which is from pre-2013) to support the idea that gender dysphoria ‘goes away’ for most young people after puberty (p 41 and 223). The cited papers have been heavily criticised (for a comprehensive account of why these studies are highly problematic see McNamara et al. 2024), and are an odd choice of literature to draw on in discussions of detransition when there is a significant amount of more recent, good quality evidence to draw on. The concept of detransition is complex and nuanced (there are multiple different types of and ways to define detransition, and each may or may not come with regret). It goes beyond the scope of this paper to go into the topic in depth (for further information see Exposito-Campos et al., 2023[16], MacKinnon et al., 2023[17]). However, estimates of detransition are generally low (Exposito-Campos et al., 2023), and regret for medical transition is much lower than many other types of surgeries and medical treatments (Thornton et al., 2024[18]). The Cass systematic review on the care pathways of young people referred to UK specialist gender services (Taylor et al., 2023[19]) found very low rates of detransition and/or regret - discontinuation of medical intervention ranged from 0-8%. Of particular note is the data the Cass team collected in the audit study of the GID service, which indicated that less than 10 young people (0.3%) - out of 3306 - had detransitioned, which is even lower than the already low rates found in two Dutch studies cited in the Cass review (van der Loos et al., 2022[20]; van der Loos et al., 2023[21]). Why the Cass team chose to ignore all of these findings in their discussion on detransition, and instead focus on old research, some of which has since been discredited is not clear[22].
- Failure to engage expertise or lived experience. In a standard guideline development process, areas where there is uncertainty regarding decision-making would lead to the involvement of two groups - experts in the field, alongside people with lived experience[23]. Cass took a different approach. The composition of the expert group with the review has been kept secret, but we know from testimony that actual experts were outnumbered by members selected specifically for their opposition to transition and affirming practice. To our knowledge, no trans or non-binary people were involved in the expert panels. This is absolutely extraordinary.
- Delegitimizing trans identities. The Cass review does not recognise or engage with anti-trans prejudice or ignorance from healthcare professionals in or outside of child and adolescent gender care, or within the review itself. Indeed, the views of professionals who take an unevidenced non-affirmative approach appear to be privileged in the review and associated literature. The unevidenced and unexamined claim that social transition may ‘encourage a child to be trans’ or that starting puberty pausing medication could ‘cause harm by making it more likely that a young person will continue on with a medical pathway (and trans identity)’ both suggest a view that a transgender identity is less preferable than a cisgender identity. There is an excessive focus on detransition and regret, despite transition regret statistics being much lower than many other medical procedures and important life decisions[24]. This focus on detransition serves to delegitimize the wishes and competency of those seeking gender-related care, and is used to justify a ban on puberty-pausing medication and exclude trans people from the Conversion therapy ban. Going forward, any policies involving child and adolescent gender care need to recognise the existence of anti-trans prejudice or ignorance among healthcare professionals, and take steps to protect service users from approaches that are driven by prejudice[25]
The critical
The Cass review could have been an imperfect document that remained fairly uncontroversial. One that expressed the gaps in the literature around medical transition, left social transition out of the medical domain, and emphasised holistic assessment and treatment of the whole person, prioritising their overall wellbeing. We certainly would not be writing this article in response to such a document.
But the Cass review had to justify a number of decisions that were made for political reasons and which cannot be justified on the basis of the evidence that it considered. These are:
- The closure of the Gender Identity Development Service (GIDS).
- A total ban in the UK on puberty-pausing medication for gender diverse young people under the age of 18.
- Strongly dissuading young people from social transition without specialist input.
In order to justify these, a narrative needed to be advanced by the review.
With regards to the now closed Gender Identity Development Service (GIDS) at the Tavistock, which was the largest and longest running child and adolescent gender service (35 years) in the world, the political and media narrative is as follows: on the basis of insufficient evidence, a rogue group of clinicians, acting with a kind of groupthink, departed from normal clinical practice and inappropriately rushed children towards medical transition. The problem is that the review has found no evidence of this whatsoever. As has been pointed out elsewhere, the GID service, following the former NHS service specifications, saw children between 6 and 15 times before referring them (if requested) to endocrinology to be considered for medical intervention (i.e. puberty-pausing medication, gender-affirming hormones or both), and only 27% of young people seen at GIDS (between 2018 and 2022 were ever referred to endocrinology to be considered for medical intervention. At a population level the number of children receiving medical intervention at any one time in the UK was infinitesimal (they would all fit onto a single London underground tube train!). There is no justification within the review for the disruption caused by the closure of the GID service and the loss of decades of clinical child and adolescent gender experience.
This closure was often justified by its proponents with reference to a CQC ‘inadequate’ report, published in 2020. What these proponents do not mention is the subsequent multi-million pound transformation project that ran for 18 months during 2021 and 2022, and the much more positive CQC re-inspection performed in 2023[26]. The key impact of this closure has been the throttling of any provision for the 1000s of children waiting on the list for assessment. The ‘old’ GiDs stopped taking new patients in January 2023. The new services contain half the staff of the old service, with virtually no experienced gender clinicians, and are having marked difficulties with recruitment; and as far as we are aware, they have only just begun to see new patients off the waiting list for an assessment because thus far they’ve only had enough staff to manage the caseload of approximately 200 young people that were transferred over from the closed GID service. So whatever your view on the correct pathway for these patients, the current offer of NO CARE AT ALL is not acceptable[27].
In terms of medical intervention, it may be argued by the review's supporters that the review does not advocate for a total ban. However, making it impossible to give puberty-pausing medication outside of a specific research project, the proposal for which has not even been written, and the lead researcher of which had only been appointed a week before publication of the review, is pretty much a de facto ban. We know that a large-scale longitudinal study was called for in mid 2022 at the latest and yet over 2 years later little progress has been made, and there is no start date in sight. The fact that any new prescriptions of puberty-pausing medication for someone under 18 is now a criminal offence in the UK may be shocking, but to those of us who were observing the Cass review it is not surprising.[28] Dr Cass was known by colleagues to be sceptical of medical transition when she was appointed to the review, after all.
Since the report’s publication, she has described the speed of the adoption of medical transition as something that she could find no example of in medicine[29]’- this is nonsense, and as mentioned above, her own review clearly illustrated this. Adoption of practice before the evidence is fully in place is absolutely standard in specialist centres[30], while in a lot of medicine, but especially mental health, clinicians have to proceed in the face of considerable uncertainty as regards outcomes.[31] The thing we have actually never seen in medicine is a treatment criminalised on such spurious grounds.
What about social transition? Here we need to take a bit of a deep dive into gender critical approaches to gender dysphoria.
The definition of gender critical approaches is contested. We offer a definition found in a book by Dr Finn Mackay[32]
“A gender critical (GC) position recognizes the immutability of biological sex and the existence of only two biological sexes in humans, these being male and female, acknowledging variances of sexual development in a minority of cases. A GC position does not recognise gender identity, and does not believe it exists. Gender critical groups (e.g. LGB Alliance) believe that lesbian and gay gender incongruent young people are being subject to conversion therapy when they are referred to child and adolescent gender services, and that homosexuality is under threat from trans inclusion”.
As applied to gender dysphoria, a gender critical perspective will therefore see the distress experienced by gender incongruent young people not as a reaction to conflict between a genuinely felt gender identity and incongruent pubertal development, but as a misinterpretation of distress caused by other aspects such as neurodiversity, body dysmorphism and social pressures, especially on biological females. A gender critical clinician will therefore tend to avoid affirming the young person’s identity, and prefer to explore the underlying factors behind a trans or non-binary identity, which they regard as fundamentally invalid.
The purging of experienced child and adolescent gender clinicians, and the draconian strictures on medical intervention, are part of a broader gender critical thrust which pervades the review. The section examining the reasons for the change in referral patterns is full of gender critical talking points instead of evidence or analysis.
We don’t intend to refute all these points within this post, but a couple of observations need to be made here. Firstly the surge in referrals, while seeming to be huge for a single clinic, is not, in population terms, remotely significant[33], nor is it in any meaningful way exponential[34]. Second, the Cass discussion of potential reasons for changes in referral patterns is astonishingly biased. There is little mention of the socio-cultural factors, such as changing cultural norms that allow gender diverse people to be more visible, and increased public awareness of trans people’s existence and the availability of support for gender diverse young people; there is also a dismissal of genetic factors that strongly influence sexuality and gender identity[35]. However, there is a noticeable pushing forward of speculative ideas about the influence of social media, trauma and peer influence[36]. While the discredited idea of social contagion and rapid onset gender dysphoria[37] is not explicitly endorsed, all of the constituent parts of this narrative are in place.
The review is very pre-occupied by the shift in referral patterns from people assigned male at birth (AMAB) to people assigned female at birth (AFAB), in a way that mirrors the work of gender critical writers. What the review does not consider, however, is this unequal sex ratio in child and adolescent clinics is not found in census data of trans and non-binary people[38] or in large population-based studies of trans/gender diverse young people[39], and the trend in clinics tends to disappear in adult gender clinics. Nor does the review engage with the emerging evidence that suggests that that trans girls/women come out, on average, 10 years later, than trans boys/men[40]; in which case, it is possible that we are seeing an under-representation of people AMAB in child and adolescent gender clinics, rather than an over-representation of people AFAB; and with the earlier start of pubertal development in people AFAB, and the level of misogyny in our society towards boys and men who show feminine traits, it is not surprising that people AMAB come out later. All of this, however, does not suit the Cass ‘damaged girls’ narrative, so is not considered.
The therapeutic implications of this are only obvious when you look at the wider context of the Cass process. Many of the professionals involved in the Cass review are advocates of ‘gender exploratory therapy’[41]. This innocuous sounding name is misleading. The philosophy of the approach is that rather than embracing the child's professed identity, their perception of their identity is interrogated and examined by the therapist, looking for pathological roots to the young person’s identity. There is no empirical evidence supporting this approach, in terms of its safety and effectiveness, and we, like many clinicians, have concerns that a failure to respect the child's thoughts and feelings about their gender identity will itself be a source of minority stress[42]. In our view, the key issues of exploratory therapy are 1) The implicit assumption is that a cis identity is preferable to a trans identity (we don’t subject cis young people to gender exploratory therapy!), 2) The therapy claims that you cannot explore a young person’s past trauma and gender history whilst at the same time affirming their current expressed identity. In our view there is no contradiction between these two things, and a good therapeutic alliance can only be developed through mutual respect and trust - hard to achieve if you aren’t willing to use a young person’s preferred name or pronouns. Gender exploratory therapy is also ill defined - What does a therapist do if a young person does not consent to this type of exploration? How long does one explore for? How will the therapist know when they have explored ‘enough’? What outcomes are they looking for? How would a therapist know whether a trans or a cis identity was an adaptive or maladaptive one? Gender exploratory therapy has worrying conceptual and narrative parallels to conversion therapy, and the clinicians in the new regional services are now being trained by people who are strong advocates of exploratory therapy, after the previous education team, which we were part of, was disbanded due to an insufficiently gender-critical approach.
The main reason why this matters is that that sets the tone for the whole NHS, and indeed public sector approach to social transition. We have already seen the government introduce some extraordinarily restrictive guidance on social transition in schools, practically banning it except under very specific circumstances. The Cass review only serves to buttress those who feel that preventing social transition is best for the child in the long run. It also gives succour to advocates of conversion therapy.
Conversion therapy is a harmful pseudoscientific practice which is still legal in the UK[43]. Some say that exploratory therapy is not the same as conversion therapy, but if that is true, then why do its advocates, including Dr Cass, caution against a blanket ban on conversion therapy on account that it would make it difficult for exploratory therapists to practise this approach? If an ‘exploratory’ therapist is genuinely neutral about the child's gender outcome, then they have nothing to worry about. It is the fact that the bias towards cis identity is so obvious, both in the Cass review and in the writings and training developed by proponents of gender exploratory therapists, that means they probably do have something to worry about from a conversion therapy ban.
Conclusion
Ultimately what matters about the Cass review is the impact it has on gender diverse young people presenting to services for support. For the foreseeable future, they are not going to be able to access medical intervention, which may have an uncertain evidence base, but one which broadly indicates benefit. They may, eventually, get access to assessment that will explore previous traumas, neurodiversity, and other aspects of mental health (although, for reasons we’ve already outlined, many will age out of the service before being seen, and will be shunted on to adult services). Beyond that, the new service appears to be mainly involved in a watchful waiting approach, with a side-order of ‘don’t you think you might be better off cis?’. Not only did the Cass team implement a psycho-social model with no evidence base, they made no attempt to engage with the many documented harms of no intervention.
The reason that the Review was initially commissioned was to address the failure of the NHS to provide timely, and consistently high quality care to transgender youth across the country. And that the exact opposite has happened as a result of the review. The waiting list was at 5560 when the GID service closed at the end of March 2024[44] and had risen to 5769 by the end of May 2024. Only a handful of people from the waiting list have been seen for an assessment since January 2023, and the services have now been open for 5 months. The services are struggling to recruit, yet are refusing to hire some ex-GIDS staff who desperately want to help with some of the aforementioned problems. None of the young people who were accepted to start medical treatment prior to GIDS closing have been contacted - they remain in the dark about what is happening with their care. The system is effectively at a total standstill as a direct result of the Cass review and associated political decision-making.
We can do better than this - a new government has the opportunity to adopt the good of the Cass review, reject the bad, and move away from the gender critical posturing to a more balanced, person-centred view. If they really don’t want medication given outside a research setting, they can open up the trial protocol, make it easy to enrol from any provider and give a clear timeline for commencement. They can train professionals to look after their local gender-diverse youth with respect and collaboration, not hand-wringing about social media and professional-led ‘exploration’. And they can help families, schools and other organisations to help kids be who they want to be safely- acceptance starts in communities, and gender-diverse youth have had a hell of an alienating few years. Let it stop now.
For now, we would pose the following questions to the new government:
- Service capacity has collapsed[45]. Cass’ starting aim was improving access to care. However very few children have been seen in the new services. Can the government publish demand and capacity data for the current services? Will they engage previous staff to help?
- There is currently no research protocol in place, nor any timescale for starting. While this is in development, it would be pragmatic if medical intervention could be accessed under exceptional circumstances (as Dr Cass briefed to clinicians in 2023). Will appropriate experts be engaged to decide what circumstances count as exceptional?
- Concerns about research capacity. Once the protocol is in place, can the government reassure us that there will be sufficient capacity so that all patients who might benefit can access the research? Can this be extended to all providers, or will the ban on private prescription continue?
- The terms of reference for the Cass review explicitly excluded subject matter experts and people with lived experience of gender services, and so by design the review prioritised the views of cisgender professionals with no experience in gender-related care. This paper has outlined the many problems that resulted in-part by taking this approach. Will the government commit to involving subject matter experts and people with lived experience in future policy deliberations?
- We welcome the government's commitment to a ban on conversion therapy. However, Dr Cass and several people involved in the founding of the new service have expressed opposition to the ban, on the basis that the unevidenced ‘exploratory’ approach they espouse is uncomfortably close to conversion. Will the government review the risk of continuing with exploratory approaches in the light of a ban, and consider a shift away from them?
- We note a recent report into suicide by Prof Appleby which emphasised an accepting, non-judgmental wider environment[46] . Will the government review existing guidance to ensure that it promotes such an environment, including the draft schools guidance?
Notes
[1] Germany (Austria and Switzerland) are about to publish their own review, which took 7 years to complete.
[2] MacNamara et al., 2024. An evidence-based critique of “the Cass REview” on gender-affirming care for adolescent gender dysphoria. (Microsoft Word - Cass Response 7 11.docx (yale.edu))
[3] See for example: The Cass Review - Intro - Gideon M-K: Health Nerd (substack.com), Microsoft Word - Cass Response.docx (yale.edu), https://open.spotify.com/episode/5WrYyTayPr8eHaBP5ybglE?si=Crk5dkdmQuqK8BlVAAutNQ
[4] Gideon Mayerowitz-Katz (2024) The Cass Review Into Gender Identity Services For Children - Part 5 (substack.com)
[5] Appendix 8 of the Cass review. Final Report – Cass Review
[6] The audit covered young people who had attended at least 2 appointments and who were discharged between April 1, 2018 and December 31, 2022.
[7] The Cass Qualitative study reported young people waiting up to 3 years to be seen, but as a clinician working in the service for 5 years Dr Hobbs saw many young people who had waited as long as 4 years to be seen. These wait times increased further when HHS England instructed the GID service to stop taking people off the waiting list in January 2023.
[8] The Cass Review - Intro - Gideon M-K: Health Nerd (substack.com)
[9] Germany (Austria and Switzerland) are about to publish their own review, which took 7 years to complete; the recommendations of which are starkly different from those of the Cass review with regards to social transition, psychological intervention and medical intervention.
[10] What it did find is a survey of parents, not young people, which tells you everything you need to know about the appropriateness of this approach.
[11] Minority stress factors and suicidality among transgender people (nationalelfservice.net)
[12] The Cass Review Into Gender Identity Services for Children - Part 4 (substack.com)
[13] We will explore the troubling implications of this later on
[14] The fact that the main researcher advancing these ideas is in other respects strongly anti-trans is worth noting here.
[15] SOC8 Homepage - WPATH World Professional Association for Transgender Health
[16] Exposito-Campos et al., 2023. Gender detransition: A critical review of the literature.
[17] MacKinnon et al., 2023. Detransition needs further understanding, not controversy.
[18] Thornton et al., 2024. A systematic review of patient regret after surgery - A common phenomenon in many specialities but rare with gender-affirmation surgery.
[19] Taylor et al., 2024. Masculinising and feminising hormone interventions for adolescents with gender dysphoria or incongruence: a systematic review.
[20] van der Loos et al., 2022. Continuation of gender-affirming hormones in transgender people starting puberty suppression in adolescence: A cohort study in the Netherlands.
[21] van der Loos et al., 2023. Children and adolescents in the Amsterdam cohort of gender dysphoria: Trends in diagnostic and treatment trajectories during the first 20 years of the Dutch Protocol.
[22] Green et al., 1987 and Zucker 1985 as per Cass Review p67, but also Drummond et al., 2008 and Wallien et al., 2008. It is also of great concern that the Zucker chapter advocates for conversion therapy.
[23] This is the approach that the German review took.
[24] See papers in footnotes 16,17 and 18.
[25] For more information on prejudice, cisnormative bias, pathologization and inconsistent standards of evidence in the Cass review read Horton (2024). The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children.
[26] CQC publishes report on Tavistock and Portman NHS Foundation Trust's gender identity services - Care Quality Commission
[27] https://www.theguardian.com/society/article/2024/aug/05/waiting-list-for-childrens-gender-care-rose-after-opening-of-new-specialist-hubs
[28] Please see clarifying note
[29] Hilary Cass interview: “Do I regret doing it? Absolutely not” - New Statesman an interview which contains the implausible claim that Dr Cass went in ‘with no preconceived ideas’.
[30] Dr Cass’s actual expertise is in neurodisability, a field where ante-natal repair of spina bifida has become the norm despite an equivocal evidence base as compared to postnatal intervention.
[31] The example of medication for teenage anxiety and depression is perhaps the closest analogy.
[32] Female masculinities and the gender wards by Finn Mackay.
[33] England and Wales Census data (2021); Gideon Mayerowitz-Katz (2024); MacNamara et al., (2024),
[34] Gideon Mayerowitz-Katz (2024).The Cass Review Into Gender Identity Services for Children - Part 1 (substack.com)
[35] Of course these would not account for changes in referral pattern, but an understanding of the importance of genetic factors (The Biological Contributions to Gender Identity and Gender Diversity: Bringing Data to the Table | Behavior Genetics (springer.com) puts a ceiling on how much of the change can be due to social influence, as opposed to greater acceptance and willingness to come forward for treatment.
[36] It is even insinuated that pornography might be making children trans, for which, predictably, no evidence is offered
[37] Ashley (2020) A critical commentary on ‘rapid-onset gender dysphoria’. Bauer, Lawson & Metzger (2021) Do clinical data from transgender adolescents support the phenomenon of ‘Rapid Onset Gender Dysphoria’, and Serano (2023) https://juliaserano.medium.com/all-the-evidence-against-transgender-social-contagion-f82fbda9c5d4
[38] England and Wales Census data (2021).
[39] Turban et al., 2022. Sex assigned at birth ratio among transgender and gender diverse adolescents in the United States.
[40] Romer et al., 2023. Can the divergence of sex ratios among youth seeking treatment for gender dysphoria from reported adult prevalence rates of gender incongruence be explained by current overall trends in a lifetime perspective. Conference presentation at EPATH, 2023.
[41] Interrogating Gender-Exploratory Therapy - PubMed (nih.gov)
[42] Meyer (2003). Prejudice, social stress and mental health in lesbian, gay and bisexual populations: Conceptual issues and research evidence.
[43] The Memorandum of Understanding on Conversion Therapy in the UK, version 2.
[44] According to a freedom of information (FOI) request to NHS England in April 2024.
[45] According to a freedom of information request to NHS England, at the end of May 2024, there were 5769 young people waiting for support, and that the average waiting time for a first appointment is 100 weeks. However, using an average wait time is likely to underestimate the actual time taken for many young people to be seen; a more meaningful measure would be to look at the wait times for those at the very top of the waiting list. Compounding the matter, there are now approximately 40 full time equivalent (FTE) staff across the new gender services (which is approximately half the number of clinicians the GID service employed at its peak, and yet could still not keep up with demand). Many say it’s ‘early days’ but the new services were announced over 2 years ago, and NHSE were acutely aware of the recruitment and retention issues in this area long before that.
[46] Review of suicides and gender dysphoria at the Tavistock and Portman NHS Foundation Trust: independent report - GOV.UK (www.gov.uk)
Clarifying note from Dr Davie regarding footnote 28:
Towards the end of 2020, I was called by Dr Cass, to discuss potential involvement in her review, which had just been announced. This is my recall of that conversation.
We had worked together on a NICE working group looking at medical transition, which was a separate piece of work with a different governance structure to the subsequent review.
During this NICE exercise, I had become aware of Dr Cass’s scepticism about the GiDs model.
During the call, she expressed concerns about GiDs practice. She expressed the view that it was shocking that 97% of children who went onto puberty blockers then progressed to gender affirming hormones in the GiDs service. I suggested that this might have been due to accurate triage. She recommended that I read Irreversible Damage.
The call ended and I never heard anything about involvement in the review.
This is my recollection of the conversation. It may be that Dr Cass has a different recollection.
It is important to note that I am not saying that Dr Cass did not have a right to her opinions on transition. She did not explicitly state that she had read Irreversible Damage, or that she endorsed everything in it. I am not saying that having pre-existing opinions on medical transition disqualified her as chair of the review.
However, I still maintain that the content and tone of the conversation is not consistent with the statement subsequently made in the New Statesman interview that she went into the review at the end of 2020 with no pre-conceived notions.
That is all we meant to say in footnote 28, and apologise for any misunderstanding.
.....
See also:
Colleagues Allege Cass Recommended Book Comparing Transition To The Holocaust
Critical discussions about the NHS Cass Review and its effect on transgender youth
