Summary
Although endorsed by the government, the Cass Review has met with international criticism from credible sources. TransLucent’s expert team examines the issues and offers a solution-focused approach to implementation of the Cass Review recommendations.
In April 2024, the Cass Review, also known as the Cass Report, was finally unveiled after nearly four years of the scrutiny of gender identity services by Dame Hillary Cass and her team.
Officially titled the ‘Independent Review of Gender Identity Services for Children and Young People,’ the Cass Review was met with a global wave of concern. Despite this, it was welcomed by some healthcare professionals and associations and accepted in the round by the outgoing Tory government as well as the newly formed Labour government, NHS England and the Department of Health and Social Care. Within weeks of its publication, numerous critiques from gender-identity healthcare organisations worldwide voiced their apprehension, a significant development that has been largely overlooked by the British mainstream media.
Based on the findings of the Cass Review, puberty blockers – also known as GnRH analogues were banned for under 18s within NHS services. A further temporary ban was imposed on private prescription of puberty blockers and made permanent by the Minister for Health and Social Care, Wes Streeting. The British Medical Association, the Royal College of Psychiatry and the Royal College of General Practitioners all opposed the extension of the ban.
Subsequent to the launch of the Review, TransLucent assembled a qualified multi-professional team with comprehensive experience of NHS services to investigate the report. We considered the implications of adopting its recommendations as well as evaluating the mounting criticisms arising from apparently credible sources. We also reviewed the twelve principal recommendations, publishing our response, The Cass Review: A solution-focused Approach on August 29th, 2024.
Our report identified the implications for the government of failing to address the many apprehensions being expressed by service users and their families, experienced healthcare professionals, medical associations and human rights organisations. Crucially, we offered evidence-based, easily implementable and cost-effective solutions to the issues raised. These solutions would enable a more harmonious milieu to prevail in what is universally acknowledged as a toxic and increasingly inveterate healthcare environment.
We appeal to the government to consider these proposals.
In formulating the proposals, we considered the principal concerns the Cass Review has generated:
- Methodological Issues: Although the systematic reviews informing the Cass Review were peer reviewed, the Review itself was not. Peer reviews are normally conducted by medical professionals experienced in the research, development and/or treatment of the client group. This culminated in a statement by the New England Journal of Medicine (NEJM) a highly regarded journal within the international medical community to state that, “The review thus departed from standard practice; indeed, if the US government issued a report in a similar manner, it would be violating federal law.”
- Structural Bias: The review lacked transparency in identifying its professional advisors. Those with lived experience and clinicians experienced in working with trans young people were barred from membership of the Cass advisory panel. Due to this exclusion, the Integrity Project at Yale University and the NEJM have stated that the Cass Review has a “high risk of bias according to the Risk of Bias Assessment Tool for Systematic Reviews.” It adds that the review “contravenes international standards by failing to list authors.”
- Poor Standards of Evidence: The Cass Review has been criticised for overstating the increase in referrals to the Gender Identity Development Service (GIDS), misinterpreting data, and relying on a poor evidence base to arrive at speculative or unjustified conclusions. Many professional researchers and clinicians have rejected the report’s conclusions and recommendations because of its substandard level of scientific rigour, for instance citing a Reddit survey, Scientific American magazine and opinion pieces rather than relying on robust evidence-based source materials.
- Deviates from Pharmaceutical Regulatory Standards: The New England Journal of Medicine states that the Cass Review “calls for evidentiary standards for gender-affirming healthcare that are not applied elsewhere in paediatric medicine”. Dame Cass has consistently criticised the prescription of puberty blockers for trans children as lacking in evidence despite their use for other treatments in younger children. Additionally, the Review’s outputs take no responsibility for it’s clear endorsement of the puberty blocker ban.
- Overstating the extent of Detransitioning: Despite reference to engaging with a wide range of stakeholders and examining the data of 3,306 patients, fewer than ten detransitioners were identified.
- Implausible Assertions about Clinical Expertise: The review asserts that clinicians cannot determine which young people will have an enduring trans identity. This is contradicted by the review’s own audit data showing that more than 75% of patients were not prescribed puberty blockers after multiple appointments. Additionally, more than 77% of referrals into 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. services were appropriately completed, suggesting that clinical judgment was sound.
- Failure to Consider the Harm of Withdrawing Treatment: The review fails to adequately assess the harm caused by denying medical treatment to trans youth, particularly in light of the evidence of good clinical judgement by clinicians in identifying patients who would benefit from treatment. This failure could have serious adverse consequences, including an increased risk of psychological and emotional distress, and in the most serious cases, of suicide.
- The Cass Review was Politically Motivated: While it is claimed the Cass Review was independent, Kemi Badenoch has stated that it was influenced by those who reject the medical treatment of gender identity, sometimes referred to as ‘gender-critical’. In response to a claim that the UK was able to ban puberty blockers due to a unified NHS and the interventions of JK Rowling, she tweeted: “The third reason was having gender-critical men and women in the UK government, holding the positions that mattered most in Equalities and Health. You only need to look at what the SNP did in Scotland to see what would have happened had we not intervened. The Cass Review would **never** have been commissioned under a Labour govt. Labour did not want to know. We had incredible opposition from the system on everything. It was when the ministers changed that everything changed.” – Kemi Badenoch, June 8th 2024
Translucent’s Cass Review Recommendations
In order to address these concerns, TransLucent recommends:
- The adoption of openness and transparency across all healthcare provision for trans young people
- The investigation of associations between advisors to the Cass Review and gender critical groups that seek to deny the human rights of trans people
- The creation of Trans Experts by Experience to contribute to the meaningful co-design of services
- A review of the full body of evidence across all aspects of trans healthcare
- An enquiry into the understanding of what it means to be transgender as distinct from gender questioning
- Clarity on the process and progress of new services
- The adoption of a risk-based approach to all interventions in trans healthcare
- The reintroduction of standard prescribing practices for GnRH analogues and the lifting of the ban on puberty blockers
- A study design which avoids the ethically unacceptable practice of withholding treatment for participants whose best interests are met by medical treatment
This is a brief summary of our proposals which are elaborated in our paper, The Cass Review: A Solution-focused Approach. We invite NHS England, the Department of Health and Social Care and the Minister for Health and Social Care, Wes Streeting, to discuss the Cass Review with the TransLucent team.