The recent NHS report on the care of trans children and young people uses moderate language and claims to focus on trans people’s needs. Yet it rejects almost all of the accepted medical expertise, views being trans as something like a sickness and will be used to justify denying support to thousands of young people – that’s on top of the millions of young people with mental health issues, cis and trans, already failed by the NHS. Lisa Leak and Colin Wilson explain why we should reject Cass and renew the fight for trans liberation.
Trans people around the world have faced years of attacks from the right. In particular, the right has attacked trans children and young people. Right-wingers in the US have issued blanket bans on trans healthcare, given school employees the right to physically examine students’ genitals, and legally persecuted the parents of trans children. In Britain, while suppressing resources for trans healthcare and shrugging off the intermittent suicides of trans teens on waiting lists, the Tories have issued school guidance that legitimises transphobic bullying and referred to trans identity among young people as a ‘social contagion’; the Prime Minister recently cracked a transphobic joke in the face of the mother of a trans teenager who was murdered by transphobic schoolmates.
We need to understand the Cass Review in this context. The Review is written in language which to many people will seem very measured and reasonable. But the reality beneath that language is that it aims to deny trans healthcare to thousands of children, to deny in fact that they are trans at all, and so to cause untold misery to a large and growing number of young people.
Already, people around the world with expertise in trans healthcare are expressing concern or horror at the Cass Review. Health professionals in Aotearoa/New Zealand comment that the Review “ignores the consensus of major medical bodies around the world”. Dr Aiden Kelly, a clinical psychologist specialising in gender based in Britain and Ireland, has told the Guardian that care for trans children is “going backwards” and is “far worse” than before the Cass Review. So it’s shameful, if unsurprising, that Shadow Health Minister Wes Streeting has abandoned the last shadow of pro-trans Labour policy to welcome it.
Several aspects of the Review process have combined to lead to this dismal outcome. First, Dr Hilary Cass was appointed to lead the project, to quote from the Review, “as a senior clinician with no prior involvement or fixed views in this area.” Her lack of knowledge and experience were regarded as an advantage, allowing her to make an unbiased assessment of the evidence and build a consensus about the way forward. But this ignores the fact that issues about trans people aren’t just medical questions but ones of political principle. Either trans lives are just as good as cis lives, or they aren’t. Either trans people are oppressed and people should oppose that oppression, or they aren’t. The report repeatedly regrets that discussion is “polarised”, that “there is no clear consensus and finding a middle ground is not possible”. Cass ducks these questions, writing that “Although some think the clinical approach should be based on a social justice model, the NHS works in an evidence-based way.” And so the Review addresses trans children and young people as a purely medical issue, without ever referring to the oppression which structures their lives. Cass may imagine that her empirical process exists outside of history and politics, but there are countless examples of oppressed people being falsely pathologised and ignored by medical hierarchies on exactly this basis – from the classification of homosexuality as a mental disorder, to male obstetricians exposing mothers to mortal danger, to Black patients being deprioritised for pain relief.
If Hilary Cass had no “fixed views” in this area, the same can’t be said of some of her co-authors. The task of designing the review’s methodology was given to Dr Tilly Langton, who as long ago as 2022 was identified by the Trans Safety Network as a key figure in networks promoting “exploratory therapy” in the NHS. (“Exploratory therapy” is a repackaged form of “conversion therapy”, in which the avowed purpose is to induce the patient to abandon their view of themselves as transgender or otherwise LGBTQ.)
The second step in the Review’s reasonable-sounding transphobia consists of dismissing almost all the existing evidence about trans healthcare for children. Having access to over a hundred scientific articles – peer reviewed papers in respectable journals, based on the experiences of over 113,000 children and young people in 18 countries – the Review dismisses all but two of them. They do this because most of the studies are of “low quality” because they aren’t based on double-blind trials (in which some people get a medication and some get a placebo, with neither the patient nor the people running the test knowing which is which). But it is obvious on even a moment’s reflection that double-blind trials are utterly unfeasible and unethical in the case of puberty-blockers or hormone treatments, where the medication’s effects are necessarily outwardly visible.
The fact that Cass got the job because she knew nothing about the topic at hand, and then went on to disregard a large number of studies from which she could have learned about the issues, makes it all but inevitable that the result would reflect everyday prejudices. The Review includes for whatever reason repeated examples of transphobia which is no less damaging because it isn’t obviously abusive or hateful. For example, Cass points out that some young trans people have mental health issues or are autistic. The latter observation, popular with transphobic activists online, rests on a baseless and ableist assumption that autistic people are less able to make informed medical decisions for themselves. With regard to the former, medical bodies such as the American Medical Association, which has a membership of over a quarter of a million doctors, acknowledge that many trans people have mental health issues. They explained in 2021 that this was the result of discrimination in society: “the increased prevalence of these mental health conditions is widely thought to be a consequence of… the chronic stress from coping with societal stigma… and discrimination”. This is not a reason to withhold trans-related care. The Cass Review, however, stresses over and over how “complicated” this makes everything – trans young people face “complexities and challenges”, exhibit “complex multi-faceted presentations” and so on. And “working through this multi-layered developmental process takes time”. Talk of holistic, individualised approaches sounds like something to support – and in the abstract, it would be. But in practice, the risk is that this comes down to an endless postponement of care, including for young people about to go through the wrong puberty – which amounts to conversion therapy.
Cass may imagine she occupies some moderate middle ground, but the Review speaks of gender dysphoria as something that may “resolve”, talks about ensuring that “options remain open and flexible for the child” and frets that children who have socially transitioned are more likely to medically transition later. Cass’s linkage of trans identity to mental health issues and autism implies that being trans is a pathology, so that for a child to end identifying as cisgender is the desired-for outcome, and medical transition is by implication a failure. Better to “leave options open” and hope they grow out of it.
This kind of transphobia shows itself in the Review time after time. We read that “Whilst some young people may feel an urgency to transition, young adults looking back at their younger selves would often advise slowing down.” Who are these anonymous young adults? How have their views been canvassed? What has happened to the earlier concern that claims be well evidenced? In the same vein, we’re told that “the percentage of people treated with hormones who subsequently detransition remains unknown due to the lack of long-term follow-up studies, although there is suggestion that numbers are increasing.” Who is making this suggestion? Why is it credible enough to be mentioned? As regards services for trans adults, “a number of current and past GDC staff have contacted the Review in confidence with their concerns.” This merits inclusion even though services for adults were never part of the project’s remit. A process which has dismissed dozens of research reports because their evidence wasn’t “robust” is not above relaying transphobic gossip.
The final problem with the report is that its benign-sounding recommendations bear no relation to the current reality of the NHS. Some 5,000 kids are currently waiting for specialist gender support, so far from young people receiving blockers or hormones too quickly – as Cass implies by calling for the process to be slowed down – many don’t get seen before they are transferred to the queue for adult services at age seventeen. CAMHS, the Child and Adolescent Mental Health Service, is on its knees. In the south London borough where I work in a health charity, CAMHS doesn’t have the resources to see children who are threatening suicide – young people only get a service when they have made an actual attempt. I’m told that young people know this and self-harm so as to access care. So, when Cass talks about providing care to trans kids as part of integrated provision, the risk is that they disappear into the great void that is children’s mental healthcare and get no support at all.
The Cass Review is, then, a serious attack on the rights of trans kids, and now on trans adults too, as NHS England announces a similar review of adult Gender Identity Clinics. Rather than a serious piece of medical commentary concerning the welfare of children, the review is best understood as a political battering ram aimed at pushing the envelope for more transphobic attacks across society. Transphobes are ecstatic – in the Telegraph, Julie Bindel is calling for a McCarthyite witch hunt aimed against all clinicians, education workers and therapists who have ever provided gender-affirming healthcare. Although the review itself simply asserts opaquely that the existing evidence for trans healthcare is “insufficient”, the media are busily misrepresenting the review as a trove of solid primary evidence that shows trans healthcare to be harmful or ineffectual. This means that the carefully phrased responses of Stonewall or Mermaids – who are “concerned that some of the language in the report is open to misinterpretation” – don’t come close to what’s needed. What’s needed is protest. The situation is grim, but we should remember where our strength lies. There are Prides up and down the country where the case in defence of trans people can be made. London Pride, for far too long dominated by corporates and only accessible with a wristband, needs to become a huge show of defiance to the transphobes. The LGBT networks that exist in every union must become involved. The media and politicians are siding with the transphobes – but millions of people in Britain are sick of the Tories, and of their scapegoating migrants and trans people. Just as protest has shifted attitudes to lesbian, gay and bi people in the last forty years, it can win acceptance of trans people too.
Trans Strike Back has called a protest in London. Assemble at Parliament Square from 11.30am on Saturday 20 April. More information.
