Posted by The long-awaited Cass review of gender identity services (Gids) for children and young people is finally here, and people with a wide variety of views appear to be welcoming it. In more civil, fact-based times, in which transness was accepted as just another example of human variation, this outcome could be to its credit: appropriate for a review of clinical services by an expert clinician.
However, we do not live in such times. Instead, in recent years, the UK has fallen to 15th in European LGBT+ equality rankings (in 2016, the UK ranked third) and was highlighted by the Council of Europe alongside Hungary, Turkey and Russia as a state where LGBT+ rights are under attack from political figures, including governments. We are also experiencing a steep rise in transgender hate crimes, which a UN report directly attributes to “the toxic nature of the public debate surrounding sexual orientation and gender identity”.
This context is important for understanding the Cass review’s rather confounding reception. Based on the coverage in the UK’s rightwing media, where equality for trans people is most loudly and regularly opposed, you might have been convinced that Hilary Cass agrees with them and them alone: The Daily Mail’s front page hailed her as “a voice of sanity”; the Times claimed the report “rejected” the use of puberty blockers outright. However, this is not the case.
Cass criticises Gids’ long waiting lists. My involuntary immersion in this topic for almost a decade enables me to report that the trans community fervently agrees with this, and has been sounding the alarm for years. Cass criticises the lack of broader mental health care provision, including treatment for eating disorders. The community agrees, as would anyone who knows the first thing about NHS mental health provision. Cass cites the lack of autism awareness and assessment. Again, the community – well aware and unafraid of our propensity for neurodivergence – agrees. Cass calls for more and more local Gids service provision. Unsurprisingly, the trans community agrees. Cass bemoans the lack of a peer-reviewed evidence base for trans healthcare. Right there with you, Doc (although there is plenty of research you decided to exclude).
I could go on, but you get the idea. The key words – read plainly and in good faith – can hardly be disagreed with either. Care for trans young people that is “unhurried, holistic, therapeutic, safe and effective”? What’s to dislike? This is only what prospective patients, patients and their parents and caregivers have been calling for all along.
In reality, the problem has never been disagreement about how to care for trans children and young people. Rather, individuals genuinely motivated to create such services have been effectively sidelined by an overwhelmingly more powerful coalition of politicians, journalists and, indeed, healthcare workers who are motivated by an anti-trans ideology – a need to assert and somehow “prove”, to exclusion of all other possibilities, that trans people like me do not, in fact, exist. And, therefore, that we do not spend the first 18 years of ours lives as children.
What many trans adults like me fear is that Cass has fallen into the trap of reflecting and therefore given credence to anti-trans bias.
Take puberty blockers, for example. Young people hoping to be prescribed this previously-uncontroversial puberty delayer, including those I’ve been directly in contact with, usually have to wait so long for appointments that they age out of Gids before the conversation even starts. In 2022, 378 children and young people were eligible to be prescribed blockers on the NHS, a relatively small number by any measure. Likewise with masculinising or feminising hormones for under-18s. The review makes this sound like previously common practice. In reality, such a step would only be considered for someone aged 16-18 and is even rarer.
There are more insidious examples too. Cass makes reference to clinicians feeling unable to raise concerns about the slow and inadequate services being provided by Gids. Justin Webb on the Today programme asked whether this legitimate criticism of a failing service can be attributed to a fear of being accused of “transphobia”. Cass goes some way to agreeing, but then focuses on conciliation, saying, that “whatever the reason” for clinicians’ concerns, she believes everyone was sincerely trying to do their best for their patients.
That failure to add context reflects a lack of context in the report itself: in which a picture is painted of clinicians who all want the best for their young patients, and have been let down by a lack of evidence. That is not a complete picture. Take Dr David Bell, the psychiatrist behind a critical report of the Tavistock centre, and who has welcomed the Cass review. Bell is often presented as a moderate critic of Gids and yet has argued that trans children do not exist in nature but have been invented, and that cases of gender dysphoria in children can be explained by confusion caused by sexuality, confusion caused by neurodiversity, confusion caused by abuse, trauma or mental health conditions but, crucially, never by that child being, either solely or in addition to other factors, transgender. He has described “top surgery” – shorthand that trans men use for a masculinising double-mastectomy – as “bizarre Orwellian newspeak”.
He has described gender-affirming surgeries for adults in Frankenstein terms, bemoaning people like me as “sterile and lifelong patients, many facing catastrophic complications”. I don’t really want to dignify this claim with a serious rebuttal, so suffice to say that regret rates for gender-affirming surgeries consistently hover around a whopping 1%.
Bell’s views are echoed by Julie Bindel, who, reacting to the review, says the idea of trans children is a “crazy fallacy”, calls trans adults “fanatics in the grip of a demented doctrine”, likens us to Jimmy Savile, and thanks Cass for the “validation” her report provides. Bindel and Bell are both part of the Clinical Advisory Network on Sex and Gender, a gender-critical pressure group.
These views fundamentally undermine trans people’s identities and the legal basis on which our rights to things like dignity, privacy and medical care are also protected. Failing to identify such extreme opinions and push back on them in a review focused on improving care for gender-questioning children and young people is unforgivable. Giving Cass the benefit of the doubt, perhaps simply stating that trans children and adults exist seemed too basic – but in the clinical and cultural context we’re operating in, it remains vital.
If the Cass review was held under a black light, we would see the fingerprints of anti-trans ideology. I don’t believe Cass shares this way of thinking, I think she believes in evidence-based healthcare and that trans children exist. However, allowing her review to be so heavily influenced by bias is a critical failure that is hers to own.
As her work is used, as it will be, to perpetuate a broader hostile environment towards trans people in the UK, the young people she has tried to help will, understandably, feel betrayed. I take this opportunity to implore her team to keep this in mind as she calls for a similar review of services for 17- to 25–year-olds and potentially beyond. Trans adults also need holistic, safe care (doesn’t everyone?) but our clinics are in a dire state too, with up to five years to wait for a first appointment. Now, reviews hang over us too – about us but no one knows to what extent with us – that may become Trojan horses for those who would roll back or perhaps eradicate affirming trans healthcare from the NHS altogether.
Dr Cass, appeasement might get you through this short-term discomfort in the media spotlight, but please remember: it isn’t your healthcare, your rights or your everyday dignity they are trying to take away.