Formally the Independent review of gender identity services for children and young people, the Cass Review was the UK's purported effort to study the current state of knowledge on gender affirming medicine for trans kids in the UK. What it actually was was an effort to justify the same outcome the gender critcal movement temporarily achieved in the Bell v. Tavistock case, removing trans children's access to necessary medication and forcing trans children to be suppress for as long as they can.
The Cass Review is the Gender Critical movement's best effort at attacking pediatric gender affirming medicine. They spent years on it, backed by the Tory government, and many person-hours, and lots of the NHS's money. There is significant evidence that the fix was in, but that in itself does not automatically mean that they are wrong. At the end of the day, being biased is not disproof. And at the core, this is a political rather than a scientific question, no matter how either side dresses it up as purely scientific. The review is deeply political, the reactions to the review are too, and so are the reactions to the reactions by the likes of SEGM and Jesse Singal. Eventually, you must look at the identified risks, and the identified benefits, and decide who is best able to make the call. Is it Hilary Cass? Victoria Atkins? Wes Steeting? Or the child in question? You cannot dispell the moral, ethical, and political question at the heart of letting children make a contested (but very low risk) decision for themselves, so lets not even try. But lets do it based on a fair evaluation of the actual risks and benefits.
Rather than hide our political values behind a false pretense of impartiality, we will be clear about our values and our belief that everyone deserves bodily automomy, and that this necessarily requires children to have it in relation to sex and gender. We reject paternalism, and blanket assumptions about what a child can and can't understand, especially in the face of their own clear self-definition.
All that being said, nothing about these values makes us desire an ignorance of risk, nor would we want to allow children to expose themselves to grave risks without sufficient benefit just because if them. It is simply the case that the risks Cass did identify are minimal, in many cases hypothetical more than demonstrated, and they do not rise to a level of overwhelming the benefits, which Cass often seems to downplays.
This article is about the transphobia in the report itself, rather than the personal transphobia of Hilary Cass, but the start of understanding the former requires understanding the later, and understanding that she was hand-picked for this role for a reason.
The scientific and medical failings of the Cass Review are well-covered in other places, so this article will mostly focus on making a few observations about why we are so confident in declaring it a sham and a set-up.
One of the biggest tricks Cass plays is in missing the point, probably deliberately, of a lot of gender affirming care. This results in a premature narrowing of the scope of the purpose of using puberty blockers for trans patients, so we will start with a discussion of why trans kids are actually given blockers versus Cass's claims. Its worth noting that Cass appears to have had little to no experience treating trans children, which is probably exactly why she was chosen to lead the review. The NHS justifies this as being an effort to get outside eyes on the entire field of pediatric gender medicine, but what it also means is that she is less qualified as an authority than people who actually work in the field, and in a lot of cases, her fresh eyes seem to led her to fall into traps that real experts have identified long ago.
Central to all gender medicine for decades has been the concept of gender identity, as separate from sex, sexuality, gender role, and other related concepts. Cass does discuss this a bit, particularly in chapters 6 and 7 of her review, but when talking about the management of "distress", this is often missing context.
Although she does discuss gender identity, this is somewhat in the background. Instead, the Review focused heavily on something called "gender-related distress", which appears to be a term she coined herself. While she notes the fact that the term "gender dysphoria" is used in the DSM-5, and is the most prevalent term used in the literature, she does not use it except when she refers to external works. She also mentions the term "gender incongruence" from the ICD-11, but does not really use it. How "gender-related distress" differs from gender dysphoria is unclear, especially since she never defines it, and it is an odd choice for a review to adopt novel terminology without underlying research-based justification for the new concept, in part because doing so makes it harder to know whether the term used in research is actually the same as the new term.
Cass then focuses her efforts on how to alleviate this distress that trans children experience, thereby focusing on the symptom rather than the larger cause. But if a child identified strongly as a boy, as one example, and starts developing secondary sex characteristics typically associated with women, "distress" is a natural and rational response to that situation, which is best addressed, not by suppressing the normal psychological reaction, but by addressing the underlying change causing the distress. This kind of bait-and-switch is her main propasition: if kids are seeking care because of "distress", and you can manage "distress" without allowing transition, then you don't have to deal with any gender identity issues. Does she need a reminder what the title of her report is?
To hear Cass talk about this, her entire goal is merely to manage distress, as if it comes out of nowhere. This makes sense if you assume that being trans is distress, and that there's no rational reason underlying it. But the fact that people have a gender identity that can cause dysphoria has been quite well established already for decades, so she is essentially engaging in covert denial of the reality of transgender identity under the cover of medical objectivity.
For some, the best outcome will be transition, whereas others may resolve their distress in other ways.[1]
If you are familiar with the approach of conversion therapists, that statement probably seems hauntingly familiar to you. There is also no basis for the later part in the research whatsoever. For all her pretense of operating based on evidence, she never examines her own implicit biases and preferred outcomes. The only known effective treatment for gender dysphoria, or "gender-related distress", is transition.
Her next statement is laughable.
The care of this population needs to be holistic and personal.
If care is to be personal, why are broad bans on care the result of this review? If care is to be holistic, why is she ignoring the fundamental reasons trans kids seek medical transition and focusing only on ill-defined "distress"? And if those aren't the outcomes Cass intended for her review to have, why has she been silent as they have been implemented? She had no trouble finding her voice speaking up about how weak she thinks the evidence is. We have to assume the ban, which even her own review doesn't support, was the intended outcome.
Its worth looking at what the benefits of puberty blockers are for trans children, with a more holistic lens than the one Cass used.
Trans children often know from a very young age that they don't fit with their birth sex assignment. Others don't realize their gender until later, and sometimes this can seem quite abrupt to parents and carers. Puberty blockers are seen as a low-risk intervention to halt unwanted bodily changes that may be difficult and expensive to reverse later, if they can be reversed at all.
Cass makes an interesting observation that we will examine at length:
- The original rationale for use of puberty blockers was that this would buy ‘time to think’ by delaying onset of puberty and also improve the ability to ‘pass’ in later life. Subsequently it was suggested that they may also improve body image and psychological wellbeing.
- The systematic review undertaken by the University of York found multiple studies demonstrating that puberty blockers exert their intended effect in suppressing puberty, and also that bone density is compromised during puberty suppression.
- However, no changes in gender dysphoria or body satisfaction were demonstrated. There was insufficient/inconsistent evidence about the effects of puberty suppression on psychological or psychosocial wellbeing, cognitive development, cardio-metabolic risk or fertility.
- Moreover, given that the vast majority of young people started on puberty blockers proceed from puberty blockers to masculinising/ feminising hormones, there is no evidence that puberty blockers buy time to think, and some concern that they may change the trajectory of psychosexual and gender identity development.
- The Review’s letter to NHS England (July 2023) advised that because puberty blockers only have clearly defined benefits in quite narrow circumstances, and because of the potential risks to neurocognitive development, psychosexual development and longer-term bone health, they should only be offered under a research protocol. This has been taken forward by NHS England and National Institute for Health and Care Research (NIHR).
It seems like Cass could have benefitted from some expectation setting. Trans kids going through puberty are often experiencing huge and increasing "distress" related to the ways their bodies are changing. Puberty blockers do not cause the changes that they want, but they can stop the changes that they don't want. The fact that this means things may not be getting better, but at least they aren't getting worse is an important result clinically. She does not seem to grasp that.
Moreover, the statement #83 in bold is absurd. She notes that the vast majority (but importantly not all) of kids who start on blockers graduate to hormones, and then suggests that this might mean that puberty blockers are causing the kids to be trans. But trans kids are a tiny minority of the patients who use these medications. If they caused gender dysphoria, or otherwise caused children to be trans, you would see kids with central percocious puberty, and cancer patients suddendly coming out as trans. The fact that that does not happen means that her suggestion can't be true. Puberty blockers do not cause gender dysphoria.
And finally, #84 is a purely speculative risk for which no evidence exists. She has advanced a hypothesis, and without testing it at all, she apparently advised the NHS that the risk was so high that they couldn't even wait for her final report to act. On what basis? Where is her evidence that these things are real concerns and not her imagination? We know that there are kids who have been on pubery blockers at the same ages as this cohort, so why have they not been able to document these risks with positive evidence?
Cass is, quite clearly, ignoring the most obviously interpretation of the facts: most trans kids who go on puberty blockers graduate to hormones because they really are trans, and that was always going to be the result. This suggests that the criteria for accessing puberty blockers are too stringent, if anything, and that trans kids should be offered hormones or blockers more quickly. Instead of absurd alternate theories with no scientific basis, she should have recommended that. Its a little hard to believe that she, in good faith, truly believes that kids move on from puberty blockers to hormones because of the blockers themselves.
Cass does note that pubery blockers are given on the NHS at an average age of 15, which for many kids is far too late for them to be of any use. By 15, most children are close to the end of puberty. This could be one reason for her finding that they don't demonstrate a benefit, and it's probably a result of the absurdly gatekept processes and the long waiting lists. They would be far more effective if given much younger.
In any case, Cass validated that puberty blockers did the one thing they actually are intended to do: halt puberty for a time while the next step is determined. And, another thing Cass failed to mention is that often, that's the system catching up to a trans child's own self knowledge. Trans children should not be penalized for a health care system that won't accept them with further delay and denials of care, especially at the ages where intervention is most useful.
Prior to the bans on puberty blockers, and the Bell v. Tavistock decision, decisions about gender affirming health care by children in the UK were handled with something called Gillick competence. Gillick competence was named, ironically, for a person who fought against it, Victoria Gillick. Gillick sought a declaration that prescribing contraception was illegal because the doctor would commit an offence of encouraging sex with a minor and that it would be treatment without consent as consent vested in the parent. She lost at the High Court, and then won an appeal, and then finally appealed to the House of Lords, who ruled that the issue rested on consent.
They ruled:
As a matter of law the parental right to determine whether or not their minor child below the age of sixteen will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to understand fully what is proposed.
— Lord Scarman
It's significant that the decision here was about the prescription of contraception. The Lords basically decided that as long as the child understood the decision they were making, at least as well as anyone could, it was up to the child. And when it comes to birth control, all the limits and uncertainties, and the many controversies surrounding it, children contemplating taking birth control generally have those same choices still.
Imagine instead if decisions about contraception, abortion, and other medical treatments deemed controversial were held to the standard of Cass. Imagine if, instead of informed consent, it was required that such decisions were subject to the requirement that they demontrate a clear psychological benefit. It would be almost impossible for people who need those treatments to meet that bar, especially in the face of a good portion of the paternalistic medical establishment demanding their concerns be satisfied.
Cass's consideration of autonomy is virtually non-existent.
- The Review has heard mixed views about how young people perceive the value of a diagnosis of gender dysphoria. Many young people do not see themselves as having a medical condition and some may feel it undermines their autonomy and right to self-determination. Others see diagnosis as validating, and important when looking to access hormone treatment.
She repeats that statement verbatim, on page 146. And then "autonomy" appears only in the glossary. Self-determination only appears in the two instances of that quote. But, whether you go through a male or female puberty is a deeply personal and consequential outcome, perhaps even more than the decision to have or not have a baby, and those consequences are lifelong. What justification can be given for denying that decision arbitrarily?
It is absolutely unquestionable whether puberty blockers can safely stop puberty. They can. Even Cass admitted that. In fact, most of the patients who use them for that are cisgender, and Cass hasn't even questioned that usage of these medications. The risk of regret is present, but that risk is not something children are categorically unequipped to understand, nor is a blanket ban a reasonable or proportionate response.
The UK is an extraordinarily trans-hostile place, and the process of transitioning, even for adults, is needlessly complex and humiliating. Practices that have been abandoned in other parts of the world are still required for things like receiving a Gender Recognition Certification, and many in the medical field are ignorant, or outright hostile, to transgender people. This is especially true of chidren. But the Review completely ignores the widespread, institutional hatred and discrimination transgender children face trying to access care.
In fact, she seems far more worried that clinicians who dissent from the established consensus should have their voices heard than she is that trans children should be heard about their own care, or the fact that enabling unsupportive clinicians to have greater voices risks silencing the voices of the people directly impacted by medical paternalism.
In her foreward to the final report, she muses:
Despite the best intentions of everyone with a stake in this complex issue, the toxicity of the debate is exceptional. I have faced criticism for engaging with groups and individuals who take a social justice approach and advocate for gender affirmation, and have equally been criticised for involving groups and individuals who urge more caution.
This is a bizarre, obfuscating juxtoposition, but her actual position is legible from it. What does she mean by a "social justice approach", and how is the large issue of social justice relevant to pediatric transgender medicine? This sounds like a right-wing framing. In fact, it sounds like the sort of criticism she might receive from her personal friends. Meanwhile, "groups and individuals who urge more caution" is a very strange way to describe the people who advocate for disaffirming approaches and conversion therapy based on absolutely no evidence. It's certainly unlikely to have been the phraing of the criticism she received for it, so this must be her reinterpretation of the criticisms. We know that she has engaged to some extent with people connected to anti-trans groups. Is that who she's referring to?
It would be helpful to know which groups that she engaged with she's calling "social justice"-focused, to see if they would identify themselves that way, or if they would accept the implication that they prefer an incautious approach. It would also be helpful to know what groups she thinks offer a more cautious approach. She clearly doesn't spell it out to avoid making her own position clearer.
If these are the two sides, she is clearly on one side. If she thinks it's more cautious to deny medications that are known to be safe, with no explanation for why they would suddenly become dangerous when trans kids uses them, and offer useless talk therapy and "watchful waiting", a euphamism for medical neglect, she's a convertion therapist. If she thinks it's "social justice" to want children who are part of a tiny, hated minority group to have access to the very same medications other children do, she clearly isn't an ally to those children.
Indeed, she seems more concerned that dissenters from the medical concensus are "afraid" to speak their minds, despite ample evidence to the contrary.
If she were an honest player in all this, she would acknowledge the fact that the debate is toxic specifically because of the powerful, well, funded anti-trans movement. She doesn't even mention it. She just lays out a false equivalance. Transgender kids and their famiilies demanding medicines they know will help them are not the source of the toxicity.
In fact, later in the report, she make reference to social justice again, and again, it seems derisive or pejorative:
Although some think the clinical approach should be based on a social justice model, the NHS works in an evidence-based way.
It's hard to read this any other way than that she is a right-wing anti-SWJ crusader showing her colors. Even if you doubt the medical and scientific consensus around the affirming approach, describing trans kids seeking access to necessary medicine in accordance with that consensus that they believe will help them is not reasonably construed as a "social justice" demand beyond what the NHS already is supposed to be providing for everyone.
The Cass Review has the following passage:
Others of you have said you just want access to puberty blockers and hormones as quickly as possible, and may be upset that I am not recommending this. I have been very mindful that you may be disappointed by this. However, what I want to be sure about is that you are getting the best combination of treatments, and this means putting in place a research programme to look at all possible options, and to work out which ones give the best results.
It should be shocking to witness a physician, pretending not to have enough evidence to treat a population of patients, when the patients themselves clearly know what they need. To most trans people, the usefulness of puberty blockers at a stage, particularly when hormones aren't immediately available, is so obvious as to not need explaining.
The fact that puberty blockers are widely used, known to be safe, and offer benefits for trans children that are not available by delaying care should be the end of it. But for some reason, that's not good enough.
In her interview with the British Journal of Medicine[2], at about th 8-9 minute mark, Cass talks about when she does think it is appropriate for trans children to receive affirming care. She states
I think what is very important is that you don't make those decisions (about whether to medically transition) in a state of mental distress. You make those decisions in a much more robust state.
But this is a catch-22, because she's only conceived of transness in terms of distress. If you have to be distressed to be trans, but you can't decide to transition when under distress, exactly which kids does she think deserve access to this medicine?
The most charitable interpretation of Cass here is that she is showing her ignorance of the topic. It has been common practice with trans patients for some time to address their gender issues first because a lot of other issues are downstream of that one.
There are currently no psychological maladies that are known to cause gender dysphoria, or "gender-related distress". But there are several psychological conditions which can be caused by gender dysphoria. Demanding that trans children become psychologically healthy before maybe receiving care, on a no guarantees basis is likely a functional ban on their care in many cases. It is also extraordinarily cruel and unnecessary. Doctors who actually work with transgender children often report that with proper medical support for their transitions, these children thrive and many of these other problems resolve themselves. Undoubtedly, children who do manage to resolve their other mental health-related issues will be told that they arent eligible for gender affirming care because they are no longer in distress.
Whether by ignorance, or more likely malace, Cass is recommending conversion therapy. In no other area of medicine would it be considered reasonable to demand that patients must first become well in order to receive care.
The term "risk" appears in the Cass Review 113 times. It is the main topic of a section entitled Understanding intended benefits and risks of puberty blockers. It identifies several main risks:
There's really no evidence offered by the review to support this, and it's unclear how you could study it in a way that would be ethical and objective. Cass offers no evidence to support the idea that this will definitively happen, it's just a possibility mentioned. This appears to be a hypothetical risk, but not an established risk.
Similar to the above, this is a hypothetical risk. It's true that any shift in pubertal timing could have an impact on this, but whether that presents a genuine risk is not established either way, but it's also true that this is as much a hypothetical possibility in cisgender children experiencing central precicious puberty as it is in transgedern children. More reasearch would be required to establish a genuine risk here, but the fact stands today that there is no such risk established, and there are many adults who have used these medications at various times who do not appear to be neurocognitively disables, so if this is a risk, it can't be a certain outcome, if it is even possible.
This is a risk, but it is one for which clear and effective remidations exist, as Cass acknoledged.
A recent paper suggests that for transgender females it is recommended to wait until Tanner Stage 4 to allow adequate penilegrowth for vaginoplasty (Lee et al., 2023).
Whether a child wishes to do wait as described seems like a proper subject to Gillick competence.
Cass says:
Multiple studies included in the systematic review of puberty suppression (Taylor et al: Puberty supression) found that bone density is compromised during puberty suppression, and height gain may lag behind that seen in other adolescents. However, much longer-term follow-up is needed to determine whether there is full bone health recovery in adulthood, both in those who go on to masculinising/feminising hormones and those who do not.
It's certainly not controversial to note that bone density is compromised while puberty is suppressed, but the importance of this is extremely overstated by anti-trans activists like Cass. Research suggests that this is concern should disappear with the introduction of sex hormones, either via resumption of endogenous puberty or via exogenous hormone supplementation.[3] In any case, time on puberty blockers should probably not be indefinite, and most transgender children would usually prefer to move on to hormones in any case.
The relevant portion of Cass reads, in part:
In some instances, it appears that young adults are reluctant to stop taking puberty blockers, either because they wish to continue as non-binary, or because of ongoing indecision about proceeding to masculinising or feminising hormones. For others, there may have been a delay in adult services taking over their care.
It is true that non-binary people may have to move on to sex hormones for health reasons, and that may be a difficult decision. It is not true, however, that that applies to all trans people, and it is even possible to chose to mix endogenous and exogenous hormones to achieve different outcomes safely. And the last concern, that there may be delays getting actual hormones or getting adult services, is a fault of the system, not the treatment.
Taken all together, none of these alleged risks seem all that severe, and none of them rise to the level of overriding Gillick competence. Nearly all of them are speculative, and those that aren't have clear mitigations.
So, lets look at what the study called the Intended Benefits, but I think it's more accurate to call them risks of inaction.
This is where Cass made one of her most implausible leaps of logic. She said:
These data suggest that puberty blockers are not buying time to think, given that the vast majority of those who start puberty suppression continue to masculinising/feminising hormones, particularly if they start earlier in puberty. It was on the basis of this finding that the High Court in Bell v Tavistock suggested that children/young people would need to understand the consequences of a full transition pathway in order to consent to treatment with puberty blockers ([2020] EWHC 3274 (Admin)).
It's notable that Cass takes up the legal argument rather than the medical one, given her background and expertise. For one thing, 8% is not the same thing as 0%. And for another thing, this literally penalizes trans children for being right about themselves. If a larger percentage of children chose not to continue to hormones, would Cass have argued that too many children were getting referred?
But a big reason that children get put on puberty blockers is that the medical systems refuse to provide them hormones right away.
Reducing gender dysphoria/improving body satisfaction
Psychological and mental health improvements
As Cass acknowledged, several of the studies she looked at found benefits here.
14.27 As outlined in Chapter 2, the original Dutch protocol (de Vries et al., 2011b) found improvements in mental health in a pre-post study without a comparison group, but the GIDS
early intervention study (Carmichael et al., 2021) did not replicate this finding. The systematic review on interventions to suppress puberty (Taylor et al: Puberty suppression) identified one other good quality study (van der Miesen et al., 2020), which produced an intermediate result with improvements in some mental health measures but not others.
The Dutch Study says, in part, the following:
Behavioral and emotional problems and depressive symptoms decreased, while general functioning improved significantly during puberty suppression.[4]
Cass actually did talk to transgender adults about the outcomes:
Although there is a lack of long-term outcome data for children and young people in adult life, the Review team has been able to talk to both young people and older adults about their experience of early access to puberty blockers. This has been particularly important for the transgender women, who were able to access puberty blockers before developing facial hair and dropping their voice.
So, yeah, they know very well that there are benefits to puberty blockers, direclty from the mouths of transgender people themselves.
This should actually be the end of it. But that isn't the purpose of the Review, so the nightmare continues.