The Cass Review – Interim Report Review

Late last week I was doing my usual check on The Cass Review website to see if there had been any updates. Nothing has been posted since 12th October 2021.

On Thursday we found out why, almost 5 months since the last update and The Cass Review have released their interim report.

Was it worth it? Not really.

(Note : I use ‘young people’ as shorthand throughout, it applies to both children and adolescents, both of whom are people)

What’s been published is fundamentally, seriously flawed.

In a desperate attempt to appear neutral and unbiased, it presents unevidenced trans hostile viewpoints and assertions uncritically and as if they are on a par with international best practice & credible evidence. It uses trans hostile phrasing repeatedly, ignores credible evidence, makes a number of unevidenced assertions while at the same time providing evidence that being trans is undesirable, contradicts itself repeatedly, misrepresents it’s own data and presents research from such trans hostile luminaries as Zucker and Littman as if they’re credible voices in the field.

Yes, THAT Littman.

It doesn’t tell us anything that we in the trans community didn’t already know about the existing service, and at it’s heart doesn’t offer any real solutions either, looking increasingly like an attempt to kick the problem down the road while continuing to pathologise the identities of trans people, despite the platitudes espoused at the start.

More worrying are the implications of just how badly the NHS have mismanaged the service, and that it took this report to highlight the scale of that mismanagement, which they appeared to be completely unaware of – mirroring the failures with the adult service. Then it tries to gloss over those failures.

The report is also over long, repeating itself several times over for no apparent benefit, save maybe to try and justify the length of time it’s taken to produce. While it provides some background and history, that is often glossed over or misrepresented to paint things in a better light than that cast by reality.

It’s clear that the Review has no understanding of trans people or issues, which ultimately leads to the meandering mess that we’ve seen published.

I’ve been very critical of the Cass Review in an ongoing blog I’ve been keeping here at Steph’s Place (Parts 1,Part 2), and unfortunately this just adds to the mounting evidence that the Review is structurally flawed and biased against trans people from the start.

OK, so if that’s the short version, you had better buckle up for the long one. I hope you have coffee. Lots of coffee.

Caveat – This is based on an initial, fairly in depth read through, however the report is such a mess that it will probably take several read throughs to get to all of the nuances and problems, assuming I have the spoons to do that. I’m also not an expert in several of the areas (such as systemic searching of research), but have incorporated feedback & comments from people who have much more expertise in the area. So think of this as a fairly knowledgeable layperson’s review, with some process / analysis perspective thrown in.

As such, all mistakes my own, and happy to correct obvious errors based on feedback – just let me know.

That said, just this one pass throws up more than enough to be deeply concerning about the future of trans healthcare for young people and children in the UK, so it’s little wonder that the usual suspects are celebrating it as a win already.

It’s such a mess that it’s difficult to know where to start, and if I do this page by page it’ll be like War and Peace – so I’ve tried to break it down into broad categories and talk generally, rather that address issues point by point – although I will bring some of those points up.

And last but not least – this is just a generalised breakdown of the bigger issues within the report. There are many, many others of smaller scale.

The Good

Let’s start with the good stuff, because there does seem to be some. At least I’m assuming it’s good based on a charitable reading, some of which I’ll revisit later.

– Dr Cass includes a letter to affected young people stating that puberty blockers and hormone treatments won’t be removed.

– The report absolutely shreds the existing service, backing up what the CQC found, although it glosses or talks obliquely about the reasons why. It also highlights the need for the service to be more localised, conveniently falling in line with the NHS ‘regional’ strategy for services.

– It highlights the serious failings of clinicians and the endocrinologyendocrinology https://en.wikipedia.org/wiki/Endocrinology Endocrinology (from endocrine + -ology) is a branch of biology and medicine dealing with the endocrine system, its diseases, and its specific secretions known as hormones. It is also concerned with the integration of developmental events proliferation, growth, and differentiation, and the psychological or behavioral activities of metabolism, growth and development, tissue function, sleep, digestion, respiration, excretion, mood, stress, lactation, movement, reproduction, and sensory perception caused by hormones. Specializations include behavioral endocrinology[1][2][3] and comparative endocrinology. service too, verifying what we already suspected from the Dr Webberley Tribuna and from those who have been through the system – mirroring the adult services, assessments are often based on clinicians subjective opinions, and that endocrinology for young people is run like an unchallengeable fiefdom by one person.

– The Review also clarified that puberty blockers aren’t actually ‘experimental’ and the NHS has not classed them as such since 2014, which bring into serious doubt why the web page was changed a couple of years back to make the statement that they were experimental. Will the NHS change that page now the cat is out of the bag?

– It also highlights that there is a need for help for detransitioners, something trans people have been saying for years.

– And in a surprising show of insight, it even highlights that DSM-5 is out of date, relying on gender stereotyping for some of it’s criteria.

And that’s pretty much it.

The Bad & The Ugly

This is where it gets tricky to unpick, because from this point on the Review ties itself up in knots. Hopefully this will help to make some sense of things.

Uninvolved = Unbiased, right?

The assumption that The Cass Review is neutral and unbiased is at the heart of many of the reasons why this Review, and Report is fundamentally, seriously flawed.

Putting aside whether Dr Cass is actually unbiased to one side (although there is evidence that suggests she holds trans hostile views), she was picked because she doesn’t work in the field and as such should be neutral, and able to interpret the arguments neutrally. This approach ignores several fundamental biases and makes a fatally flawed assumptions from the start.

The first is that Dr Cass is cisgender. No cisgender people are unbiased when it comes to trans lives, but they have excluded trans people from the decision making here, possibly in breach of The Equality Act, and have done so on the assumption that trans people are biased and cannot interpret what needs to be done neutrally.

This structural bias has been embedded from the start, from a cisgender only governance board for decision making to using research apparently only from cisgender researchers and clinicians. It underlies all of the flawed assumptions that the Review itself, and the Report, proceed to make from the outset.

The second flaw is that by being ‘neutral’ the Review is uninvolved in the issues around trans lives and healthcare.

Uninvolved is just another name for ignorant, and that ignorance shines through. The Review lacks any capacity to filter trans hostile information because it is completely unaware of the forms it takes, and the inbuilt cisgender bias only serves to make that situation worse, leading to platforming trans hostile viewpoints and giving them equal weight despite being unevidenced, and downplaying trans affirmative viewpoints and ignoring credible evidence.

This is clearly shown by using research from the likes of Zucker and Littman as if they are credible voices in the field, ignoring all evidence to the contrary.

In short, these clear biases amount to a starting point of being transgender and transitioning is undesirable, and must be avoided unless absolutely necessary.

Disturbing Language

The Report is riddled with language that ventures disturbingly close to being trans hostile, as well as being hostile to children’s rights and autonomy.

Right at the start of the Report, Dr Cass quite clearly and disturbingly states :

‘The care of this group of children and young people is everyone’s business.’

Which shows a mindset in which the rights of the child and their parents, and the life and identity of that young person, are subservient to whims and tolerance of cisgender society and the NHS. It’s highly  disturbing that the head of the Review appears to believe that transgender people’s existence and identities should be predicated on social consensus, as opposed to individual, clinical need.

The care of transgender young people is not everyones business – it’s the business of the young person, their parents and their clinician. End of Story.

This is further compounded immediately in the following line :

‘We therefore encourage the wider clinical community to take note of our work and consider their own roles in providing the best holistic support to this population.’

Because what trans young people really need is the encouragement of uninformed and untrained medical professionals to chip in with their own opinions on trans lives and existence.

Other disturbing language use throughout, such as the unevidenced claims of other causes of Gender Dysphoria and ‘alternative treatments / pathways’, but there’s also vague references to ‘concerns’ from other parties – a veiled reference to the structural trans hostile movement which they can’t even be bothered to acknowledge lest they break their much touted ‘neutrality’.

Pathologisation

There is one thing that the report makes very, very clear. And that is that trans lives and identities, especially for young people, must be pathologised and medicalised under the strictest of supervision. Having lost the power of continued pathologisation of adult trans identities, they turn their sights to the more vulnerable members of our community.

It’s one of the many reasons why the existing GIDS service is an abject failure, and one the review fails to address. This approach is being abandoned elsewhere because it quite simply does not work. It was the initial approach for adult services, which have collapsed in the same way as GIDS and for largely the same reasons.

And yet there is a clear desire in the report that every step of a young persons transition must be managed by clinicians, as if by simply standardising the diagnostic process it will remove all inherent bias and subjective assessment from those self same clinicians.

It goes as far as to state that a young person shouldn’t socially transition (a personal, non-medical process) without clinical supervision – a clear breach of human rights to self determination and privacy, giving clinicians and the NHS unprecedented power over the lives and identities of those it serves.

This desire is summed up in this line (1.18 P17):

‘From the point of entry to GIDS there appears to be predominantly an affirmative, non-exploratory approach, often driven by child and parent expectations and the extent of social transition that has developed due to the delay in service provision.’

And thats highly dangerous because it causes actual harm to those who are just trying to be themselves, as well as being open to subversion by trans hostile elements to ensure that transitioning in any capacity before 18 becomes impossible.

And thats just the tip of the iceberg.

The whole report is couched in terms that essentially state ‘we know you better that you do, and you need to do what you’re told’, and continues to give primacy to mental health practitioners as the arbiters of identity – at a time when the World Health Organisation and everyone else moves away from that failed, stigmatising model.

And despite the evidence from adult pilot services which shows a step change improvement to transition related care by ditching that model.

The fact that trans young people are exploring who they are on their own, successfully and without the help of the medical community shows that by and large this ‘exploration’ doesn’t need the ‘help’ of the service, but more tellingly that the medical community really don’t like not having control over other people’s lives. 

A review that is supposed to be looking at improving healthcare for trans young people and children appears to be intent on actually making it worse in terms of clinical process, then hiding that behind regionalisation which would make it more difficult to monitor and track issues.

Misrepresentations & Unevidenced Assertions

There are so many misrepresentations in the Report that its near impossible to address them all, but let’s look at some of the biggest.

Affirmative Care

At numerous points it states that many clinicians disagree with ‘affirmative care’, instead preferring ‘differential diagnosis’.

‘Affirmative Care’ is almost exclusively painted as ‘unquestioning belief’ of the young person throughout the report, echoing trans hostile sentiments.

The description of the Affirmative Model, as it appears in the Report Glossary on Page 78 is also misrepresentative of the actual process as provided by the linked research papers. If we look at the very first paper linked, it quite clearly states:

(a) gender variations are not disorders;

(b) gender presentations are diverse and varied across cultures, therefore requiring our cultural sensitivity;

(c) to the best of our knowledge at present, gender involves an interweaving of biology, development and socialization, and culture and context, with all three bearing on any individual’s gender self;

(d) gender may be fluid, and is not binary, both at a particular time and if and when it changes within an individual across time;

(e) if there is pathology, it more often stems from cultural reactions (e.g., transphobia, homophobia, sexism) rather than from within the child.

It also goes on to mythbust, something the Review seems to have completely missed because while they might be gathering research papers – they dont appear to be reading them.

Myth No. 1: Gender-affirming approaches conflate gender identity and gender expression; therefore, any child who exhibits gender nonconformity is believed to be transgender.

Myth No. 2: The gender affirmative model asserts that gender identity and gender expression are immutable and removed from social context or influence.

The British Psychological Society also had this to say on the matter, pointing to the WPATHWPATH World Professional Association for Transgender Health https://www.wpath.org SOCs, again something the review seem to have completely overlooked in both instances, failing to even point to WPATH as a reference in regards to processes or diagnostics.

Without intending to, the Report highlights that many clinicians and those involved in trans healthcare for young people really don’t have a clue what they are doing.

The Review had a clear opportunity here to address this in a clinical setting via training both for new staff and remedial for existing staff, and an opportunity to dispel harmful trans hostile disinformation for the general public.

Instead they ignore it, preferring to harm trans lives over addressing misinformation in the pursuit of appearing neutral.

Lack of Medical Consensus

In what may be the biggest misrepresentation, and possibly a direct attempt at misinformation, the Report also blatantly states repeatedly that there is no medical consensus on being trans or what gender dysphoria is, how it manifests etc.

This view is only possible if you completely ignore the whole WPATH Standards of Care, as well as the evidence from the most successful services treating trans young people around the world,  and instead take at face value the incorrect claims made about affirmative care.

Which the Review appears to have done in both cases. There isn’t a single mention of WPATH in the whole document outside of two referenced research papers by trans hostile researchers.

So we have to ask – why have the Review completely ignored international guidelines and best practice?

Playing devil’s advocate, what they may mean is that there is no consensus among NHS clinicians, once again highlighting that those involved in this arera of healthcare clearly have no idea what they are doing. And instead of addressing this, again the Report chooses to inflict harm on trans lives rather than refute these claims, in the pursuit of appearing neutral.

Gender Dysphoria Vs Gender Incongruence

The report ties itself in knots, hand wringing about ‘confusion’ between using Gender Dysphoria as defined in DSM-5, and whether it should instead use Gender Incongruence, the updated and depathologising terminology in ICD-11, which is the new international standard. Common sense dictates that you use the updated, more accurate terminology and criteria.

And in not doing so, by clinging desperately to using Dysphoria, the Review betrays it’s intent.

The desire is to keep all treatment firmly in the hands of failed mental health practitioners desperate for power over others lives and very identities, rather than shift to sexual health and only involving mental health where absolutely necessary.

The Rise in AFAB Referrals

This one is particularly egregious, again taking and presenting a trans hostile talking point at face value, and deliberately misusing the data within the Report to do so.

So what are the facts here? Has there been a ‘huge rise’ in referrals of AFAB adolescents and is this problematic?

Yes, there has been a rise. But we need to look at the numbers and how they’ve been interpreted.

Page 33 includes this graph around referral numbers, from GIDS itself.

Now, the report quite clearly states that this rise started in 2014 / 2015, a claim that is is categorically false as the graph’s own footnotes show, using * to indicate a ‘significant increase in referrals’.

Between 2009 – 2010 both AMAB & AFAB adolescent referrals roughly doubled. From that point AFAB roughly doubles each year, and AMAB every two years. This is roughly mirrored for AMAB & AFAB children too, but interestingly isn’t flagged as a problem until 2014, which seems pretty sloppy.

The graph also ends at 2016. Which is interesting when you compare to GIDS own published referral figures, which I’ve been tracking for some time. While these aren’t split by age groups, the trends show that after the published graph, the trend for AFAB young people plateaus, then drops.

It’s curious that the Review choose to completely neglect this updated information despite being in regular contact with GIDS, and instead push a trans hostile narrative that the rise in AFAB trans people is an aberration. But there’s more.

The Review hasn’t even attempted to establish what baseline referral figures for AMAB & AFAB trans young people should look like based on known estimates of the trans population.

This is really basic stuff that even I can roughly work out. Using ONS data for 2020 for 12 to 16 year olds, and the best known estimate of the UK Trans population being 1%

In other words, the referral rates indicate less than 10% of those who might be trans are being referred in a single year, far far lower than the estimated number of trans young people, and more AFAB than AMAB young people are being referred.

It’s rough, but provides a starting point instead of panicked speculation, and if I can do it – why can’t the Review?

Additionally, focusing on one cohort exclusively (AFAB) plays into right wing narratives about ‘protecting girls’, while at the same time paints AFAB young people as incapable of knowing their own minds – both standard misogynistic viewpoints.

It’s indicative of a sexist bias too. The Review and Report completely ignores the opposite question which is just as valid. I actually asked this directly, and they refused to even entertain that it was a valid question.

Given we know the ratio of binary trans people is roughly equal, why are AMAB young people NOT seeking referral at the same rates?

So again we have a situation where the Review uncritically uses trans hostile talking points which are very easily disproved, directly harming trans young people in the process, again in the pursuit of trying to appear neutral.

Other Causes of Gender Dysphoria

We covered this extensively in this article last year.  In short, neither the ICD nor the DSM list Gender Dysphoria or Gender Incongruence as a symptom of any other condition, so it is yet another unevidenced assertion by the Review and the medical community.

It also repeatedly conflates Neurodiversity and Gender Dysphoria / Gender Incongruence in the same fashion, using it as an excuse as a ‘cause’, ignoring the basic fact that you can have both at the same time, as well as research that shows gender diverse people are more likely to be ND, and ND people are more likely to be gender diverse, and that Neurodiverse people are more likely to be LGBT in general anyway.

For a Review to claim to be evidenced based, and include unevidenced claims such as this shows just how badly it’s being run.

All this particular claim shows is the inherent cisgender bias against transgender people and transitioning, the deep discomfort felt by cisgender people that transitioning is the worst option and should be avoided at all costs. This bias is shown repeatedly throughout the Report indicating the continued desire to perform ‘differential diagnosis’, which refers to ‘the methods where by which we consider the possible causes of patients’ clinical findings before making final diagnoses.’ (BMJ). They’re more intent on finding cause, than treating distress.

There are no ‘other causes’ of gender dysphoria / gender incongruence, and it’s high time the NHS & UK Medical Community got to grips with this basic fact.

Alternative Treatments

At various points through the Report, it mentions the need to find or use ‘alternative’ or ‘different’ treatments for Gender Dysphoria.

This is frankly chilling and ventures dangerously close to advocating for conversion abuse, given that there are no other effective treatments for gender dysphoria other than transition, in its various forms.

To see this claimed in the report, again without any evidence appears to be further indication of bias towards making access to treatment as difficult as possible.

It also echoes exactly the same rhetoric that was used in the Dr Webberley Tribunal by the GMC witnesses, as well as the rhetoric being used in the USA where trans healthcare for young people has been removed in Texas and Idaho – as you can see here in coverage of legal action against Texas. Rhetoric that just last night exposed a member of WPATH’s own committee for the care of young people as advocating for conversion abuse and following a large number of known trans hostile activists on social media.

Systemic Review of Research

I’ll be the first to admit this area is way out of my knowledgebase, so the following is my summary of the issues in this area, helpfully explained by Dr Phoenix CS Andrews.

What I will say is that somehow, the Review managed to return a who’s who of trans hostile researchers (such as Zucker and Littman, both of whom are entirely discredited in the field), and the Review appears to completely lack the knowledge to filter good research from bad, treating both equally.

The systematic review seems to be more thorough than most systematic reviews that get published, and doesn’t appear to purposefully include trans hostile terminology to return specific types of papers, but rather seems like a thorough search to find anything about trans children.

Data filtering and quality control should be done during the inclusion-exclusion / critical appraisal sections of the review, but  it would be difficult to do this without presenting the review as biased rather than neutral.

That said, there are several significant flaws in the process.

The first is that the review of research seems to have stopped in November 2021, and given that this is an emerging field, this type of systemic review of literature should be repeated on a monthly basis to capture all relevant research, as part of an ongoing process to ensure it is kept completely up to date..

The second is that it omits any research that includes parents of trans young people, narrowing the search in ways that are probably detrimental to any eventual findings.

Detransitioning

The Report quite clearly indicates a need for help for those who detransition, but the way it is framed is disturbing, again buying into trans hostile claims that have little evidence while ignoring existing credible evidence.

The only research around detransition listed is from the known, trans hostile biased and thoroughly discredited Lisa Littman of ROGD infamy.

Part of this is the failure to keep up to date with research (such as this paper), and part appears to be ignoring older papers like this one. Part of this may be due to using the wrong language (ie failing to search on regret rather than detransition), which just exemplifies the structural failures and weakness in the Review composition and Governance by excluding trans people and subject matter experts from the decision making process.

More disturbing however are the possible implications from this.

If we assume the desire to help detransitioners comes from an altruistic position (bearing in mind that detransitioners form around 1% of those who transition) then this is good.

However, service provision introduced to help detransitioners could easily be used to forcibly detransition those who have already transitioned, or co opted by those with trans hostile intent – aka conversion abuse.

It’s a two edged Sword of Damocles that we should be very, very careful around introducing, and any introduction must not impinge on transition related services, as well as being scaled accordingly.

So, these are my own, personal thoughts and opinions of thet review. You may disagree, as is your right.

In my opinion, the Report is largely an incoherent mess built on structurally biased and discriminatory foundations, and seems to have achieved nothing in the five months since the last update, and precious little before that.

There are glaring failures in what should be fundamental, baseline investigations, such as not even appearing to look at the diagnostic processes in WPATH and comparing them to the NHS protocols, instead focussing on much more vague targets such as research papers, then not bothering to ensure they’re keeping up to date with those in what is a fast moving, emerging field.

The Review seems to be more intent on finding a non-existent ‘holy grail’ of empirical research to answer all their questions, many of which have been formulated with an implicit, unconscious trans hostile bias, or directly coopted by the Review from the structural trans hostile movement in the UK.

The use of language throughout is disturbing, directly pandering to the trans hostile movement within and outside of the NHS and medical community. The desire to appear ‘neutral’ hurts the aims of the Review, where it should be cutting through the mess and providing clarity. Instead, under the guise of ‘neutrality’ it muddies things further, ‘both sidesing’ treatment that should be an individual, personal medical decision and then framing it as a societal problem.

The Review and Report is so intent on appearing neutral that it completely forgets what’s at the heart of what they’re supposed to be doing.

Which is finding the best path of treatment for gender diverse young people for the NHS. Instead it focuses the wants, needs and desires of a medical community that is looking for any excuse not to allow trans young people to transition.

Many within the community feel the intent of the Review was to remove healthcare for trans young people, coming swiftly as it did on the back of the failed, and arguably fraudulent Bell vs Tavistock legal case. That case being overturned appears to have thrown a large spanner in the works of the Review and the NHS to try and remove treatment, and the Review now appears to be floundering for direction, unable to justify removing treatment but clearly not wanting to accept that transitioning is a beneficial, needed medical intervention either.

This could explain the lack of progress over the last 5 months, as well as the inclusion of so much trans hostile phrasing, rhetoric and unevidenced claims.

But the most telling thing is this.

The release of this report has been widely celebrated by the structural trans hostile movement. That alone should be ringing alarm bells within the Cass Review and the NHS that they’re on the wrong track, but it doesn’t seem to be registering at all.

If they actually want to improve services and treatment, they need to get off the fence and start coming down on the side of trans and gender diverse young people. If they don’t, they’re clearly showing that their sympathies lie with the trans hostile movement.

Time to be honest, and pick a side.