The Cass Review: a “damning” report into trans medicine
Calm discussion of transgender issues is rare, said The Economist. So we should be grateful for the Cass Review. Led by the distinguished paediatrician Dr Hilary Cass, it was commissioned by NHS England in 2020 amid concerns about a sudden rise in the number of young people being referred to England’s only youth gender clinic, the Gender Identity Development Service (Gids) at the Tavistock Clinic in London. Four years in the making, it is the largest review of transgender medicine ever undertaken, and its conclusions are “damning” about the treatments widely used in England (and elsewhere), particularly puberty blockers, cross-sex hormones and surgery.
Gids was set up in 1989, and initially treated fewer than ten children per year, most of whom were biological boys who thought they should be girls. By 2016, its annual caseload had reached 1,766, and about two-thirds of referrals were natal girls. Faced with this rapid and unexplained rise, medical professionals should have been very cautious, said The Spectator. Instead, “Gids ploughed on, offering powerful, often dangerous, drugs to vulnerable children”. The clinic adopted the “Dutch protocol”, derived from a single case in the Netherlands. Puberty blockers, which delay adolescence, were routinely prescribed to give under-16s “time to think”. The over-16s were prescribed cross-sex hormones, starting them on the path to physical transition. Yet Cass found that the evidence for the effectiveness of these hormones as a treatment, and for their long-term safety, “simply does not exist”. They had not been tested in full medical trials.
A total of 9,000 young people passed through Gids, said The Observer. Large numbers “were put on an irreversible medical pathway without diagnostic criteria”. They were given hormones that can “lead to infertility and damage adult sexual functioning”, and that also carry unquantified risks for brain development and bone density. Other factors that might have contributed to the children’s unhappiness – autism, eating disorders, sexual abuse, sexual orientation – were pushed to one side. Cass calls for a complete reversal of this approach: she recommends that, rather than taking at face value children’s claim to be in the wrong body, patients should be assessed and treated “holistically”. Cass has exposed a truly disgraceful episode, said Hadley Freeman in The Sunday Times. “If the number of teenage girls asking doctors to slice off one of their legs suddenly sky-rocketed”, what would the NHS’s reaction be? Concern about their mental health, presumably. But under the “affirmative model” favoured by Gids, it was seen as a form of bigotry to question children’s desire to transition. Cass cites several possible reasons for the growing numbers of teenage girls identifying as boys, including the prevalence of online porn: being a teenage girl is complicated, and the prospect of sex can be terrifying. It seems likely that gender confusion is in some cases like anorexia, which can be a reaction to a fear of becoming a woman.
Cass notes that the trans debate in Britain has become toxic and polarised, said Sean O’Grady in The Independent. And it seems that the report itself risks becoming obscured by this divisive atmosphere. We should note that Cass didn’t reject puberty-suppressing hormones as a possible treatment; she called for it to be researched further and for medical treatment to be backed by solid evidence. And she certainly didn’t dispute the validity of trans identity, let alone equate transition with mutilation. Cass’s recommendations are welcome, said Freddy McConnell in The Guardian. She criticises Gids’s long waiting lists, and calls for better broader mental health care. However, the review has clearly been influenced by the current anti-trans mood in Britain, and by the widely held view that trans identity is merely an expression of some sort of “confusion”. It is not: “regret rates” for “gender-affirming” surgeries are consistently around 1%.
Well, that figure may be correct, said Janice Turner in The Times. But we simply don’t know. Gender medicine is “hugely suspicious of data”; it is fuelled by activism, not science. Record keeping at the Tavistock Gids clinic was terrible, so it is impossible to know the scale of the harm endured, or the benefits reaped, by the 9,000 children treated there. This, it seems, is “not a glitch, but a feature” of the field: six out of seven adult gender clinics simply refused to share their data with the Cass Review. Why? Because many clinical staff are “gender ideologues” who will brook no disagreement. “The Cass review is a magnificent achievement yet no cause for celebration.” Some progress has been made. The Tavistock Gids clinic has been closed; puberty blockers are no longer doled out to the under-18s. But implementing Cass’s recommendations in an “ideologically riven” NHS will be very difficult. This was “just one skirmish. What lies ahead is a war.”
“At the Gids clinic, it was seen as a form of bigotry to question children’s desire to transition”