Last Wednesday, Dr Hilary Cass, a British paediatric physician and researcher who specialises in disability, released the final report in the Cass Review.
The Cass Review, formally known as the Independent Review of Gender Identity Services for Children and Young People, is a four year independent review for the National Health Service in England on medical services for young people with gender dysphoria, including GIDS (Gender Identity Development Service) at the Tavistock Clinic.
The review included consulting with a range of stakeholders and people with lived experience, as well as running a multi-pronged research programme.
The final report is a carefully worded document designed particularly for the systems of power in charge of child health, wellbeing and safeguarding: health systems and their managers, medical practitioners and their professional bodies, MPs and government departments, and NGOs.
It’s also a damning indictment of the poorly evidence medical experiment that has been done on gender non-conforming children in the past decade. It’s likely to be the biggest medical scandal many of us will see.
Since Wednesday, there has been an overwhelming amount of mainstream and social media coverage. This is a dam breaking because part of the picture of the past ten years had been the strategy of No Debate and the degree to which this has meant little MSM exploration of the issues around child safeguarding.
I’m going to put up a few posts with links to useful material for people to read so they can get their head around what is happening, including the relevance for New Zealand. The post today is an introduction to the Cass Review.
If you want to get the full breadth of the discussion and debate as it is playing out currently, get a twitter account.
The Cass Review
Main website and terms of reference: https://cass.independent-review.uk/
Interim report (Feb 2022): https://cass.independent-review.uk/home/publications/interim-report/
Final report (10/4/24): https://cass.independent-review.uk/home/publications/final-report/
Issues of medical and research validity
I’m including the following two resources because one of the reactions to the final report from gender identity activists and lobby NGOs has been a superficial attempt to undermine the medical and research credibility of the review.
From the British Medical Journal Editorial, by Editor in Chief Kamran Abbasi (11/4/24):
One emerging criticism of the Cass review is that it set the methodological bar too high for research to be included in its analysis and discarded too many studies on the basis of quality. In fact, the reality is different: studies in gender medicine fall woefully short in terms of methodological rigour; the methodological bar for gender medicine studies was set too low, generating research findings that are therefore hard to interpret. The methodological quality of research matters because a drug efficacy study in humans with an inappropriate or no control group is a potential breach of research ethics. Offering treatments without an adequate understanding of benefits and harms is unethical. All of this matters even more when the treatments are not trivial; puberty blockers and hormone therapies are major, life altering interventions. Yet this inconclusive and unacceptable evidence base was used to inform influential clinical guidelines, such as those of the World Professional Association for Transgender Health (WPATH), which themselves were cascaded into the development of subsequent guidelines internationally (doi:10.1136/bmj.q794).7
https://www.bmj.com/content/385/bmj.q837
My emphasis added, because this applies to New Zealand.
Of particular note is this tweet from Abbasi on the same day,
An overview of the Cass Review
The Times published an introduction to the issues: Nine key findings from the Cass report into gender transition (earliest archived version) 10/4/24,
Gen Z and online porn
Cass paints an alarming picture of an anxious and distressed generation of digitally savvy young women and girls, who not only are more exposed to online pornography and the wider problems of the world than any previous generation but also consume more social media and have lower self-esteem and more body hang-ups than their male peers.
Lack of evidence for medical pathway
Rather than affirming children’s gender identity with medical treatment, the report calls for a holistic approach that examines the causes of their distress. It finds that, despite being incorporated into medical guidelines around the world, the use of “gender-affirming” medical treatment such as puberty blockers is based on “wholly inadequate” evidence. Doctors are cautious when adopting new treatments, but Cass says “quite the reverse happened in the field of gender care for children”, with thousands of children put on an unproven medical pathway.
Mental health
The increase in gender clinic patients “has to some degree paralleled” the deterioration in child and adolescent mental health, it finds. Mental distress, the report says, can present through physical manifestations, such as eating disorders or body dysmorphic disorders. Clinicians were often reluctant to explore or address co-occurring mental health issues in those presenting with gender distress, the report finds. This was because gender dysphoria was not considered to be a mental health condition.
Puberty blockers
The report says there was “no evidence” puberty blockers allowed young people “time to think” by delaying the onset of puberty — which was the original rationale for their use. It finds the vast majority of those who start puberty suppression continued on to cross-sex hormones, particularly if they started earlier in puberty.
There was insufficient and inconsistent evidence about the effects of puberty suppression on psychological or psychosocial health, it says, and some young females had a worsening of problems like depression and anxiety.
Cass says there is “some concern” that puberty blockers may actually change “the trajectory of psychosexual and gender identity development”.
Cass also raises concern about the impact of puberty blockers in developmental and long term health, including brain function and bone density. The key takeaway here is the lack of solid medical research to support use for gender dysphoric children.
Social transition
The report concludes it was “possible” that social transition, including the changing of a child’s name and pronouns, may change the trajectory of their gender development. It finds “no clear evidence” social transitioning in childhood has any positive or negative mental health effects, but that children who socially transitioned at an earlier age were more likely to proceed to medical treatment. A more cautious approach to social transition needs to be taken for children than for adolescents, it concludes.
Rogue private clinics
Long waiting lists for NHS care mean distressed children are turning to private clinics or resorting to “obtaining unregulated and potentially dangerous hormone supplies over the internet”, the report says.
Some NHS GPs have then felt “pressurised to prescribe hormones after these have been initiated by private providers”, and Cass says this should not happen.
Detransitioning
Cass says some of those who have been through medical transitions “deeply regret their earlier decisions”. Her report says the NHS should consider a new specialist service for people who wish to “detransition” and come off hormone treatments. She says people who are detransitioning may be reluctant to return to the service they had previously used.
One of the most unconscionable aspects of wider society’s response in the past decade as been the refusal to listen to young people who have been through varying degrees of medical transition, or to minimise their experience or relevance.
As an example please read this first hand account of medical/surgical transition and detransition, and the lifetime of disability, pain and distress that transition can bring, from Ritchie/TullipR. Keira Bell was one of the first detrans people to challenge the radical gender treatment orthodoxy in the UK (she was treated at the Tavistock). Stories like this are why the Cass Review came into being.
NHS identity numbers
People who transition can be given new NHS numbers, making it very hard to track their health outcomes from that point onwards.
This ties into the refusal by adult gender clinics in the UK to share crucial data to the research team during the Cass Review. The UK government’s Health Secretary has now ordered the data to be released, as well as a similar review of the clinics themselves.
Toxic debate
Cass has called for an end to the “exceptionally toxic” debates over transgender healthcare after she was vilified online while compiling her review. In a foreword to her 388-page report, the paediatrician said that navigating a culture war over trans rights has made her task over the past four years significantly harder.
She warned that the “stormy social discourse” does little to help young people, who are being let down by a lack of research and evidence. Cass added: “There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.
In case that’s not completely clear, it’s not gender critical feminists, whistleblowers and the large number of gender critical journalists, academics, lawyers and NGOs working on this issue who have done that, it’s trans rights activists, their allies, and the MRAs and trolls who jumped on the bandwagon as an excuse to harass women online.
Some additional themes
No Debate
No Debate was an intentional strategy apparently developed by UK NGOs like Stonewall UK. The idea was to refuse to debate anything about transgender rights and the impact on society. It was picked up by liberals and large chunks of the left as well as being taken into government departments, social services, legal services, businesses and medical services. It has been a key tool in blocking public understanding of the issues, including limiting MSM coverage, and it is central in understanding many aspects of the Cass Review.
I hope to do a specific post on this, but you can follow this hashtag on twitter on meantime #NoDebate
Other themes are
On the latter, some initial New Zealand resources on the Cass Review, puberty blockers, and the treatment of gender dysphoria.
Two press releases at Speak Up For Women,
Speak Up for Women welcome the findings of the Cass Review
Laura Lopez’s Arguments with Friends substack and on The Standard
The Standard posts on Child Gender Transition and the Cass Review
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