I should clarify… the minors thing specifically is about any form of transition.
Also, Cass’ own Twitter account follows a number of trans hate organisations and individuals but no trans advocacy groups (eg LGB Alliance, which she unfollowed today once it was spotted, but also Transgender Trend, which is still there).
Being different isn’t necessarily what makes a report good. Care to expand on your approval? Being packed by one side of a debate isn’t a good ground for a balanced evidence-based view of things. Trans people were explicitly barred from serving while people who have described them as deranged were. Can’t say that’s a good look.
Repeated one-line style unevidenced assumptions/assertions about people which don't centre their own voices (or reputable reporting which draws on their voices) don't fit with our own voice guidelines in Epiphanies.
Further examples of one-line assertions will lead to your removal from Epiphanies.
Please help me understand this, it seems like the idea that the reported conclusion that a certain medical intervention should be denied to people up to 25 cannot be actually enforced.
I don't understand the legal position but it sounds like the UKgov could decide that care should not be available to children (private or NHS).
Can they really also decide a fairly arbitrary age date cutoff for adults?
Please help me understand this, it seems like the idea that the reported conclusion that a certain medical intervention should be denied to people up to 25 cannot be actually enforced.
I don't understand the legal position but it sounds like the UKgov could decide that care should not be available to children (private or NHS).
Can they really also decide a fairly arbitrary age date cutoff for adults?
Probably? Healthcare regulation is pretty strict when it wants to be and it would be relatively simple to revoke licensing from any private provider offering gender affirming care to under 25s.
Please help me understand this, it seems like the idea that the reported conclusion that a certain medical intervention should be denied to people up to 25 cannot be actually enforced.
I don't understand the legal position but it sounds like the UKgov could decide that care should not be available to children (private or NHS).
Can they really also decide a fairly arbitrary age date cutoff for adults?
Probably? Healthcare regulation is pretty strict when it wants to be and it would be relatively simple to revoke licensing from any private provider offering gender affirming care to under 25s.
It's complicated. In general, treating someone as 18-25 as not an adult is an absolute no-no in medical law. However, no one has an absolute right to treatment so it would be theoretically possible to frame the regulations this way. I am sure it would be challenged under The Human Rights Act though.
Or simple the government can issue guidance to integrated care boards not to pay for it - which will reduce acc3s to those who can afford private healthcare.
I think it they try and do this someone should it to judicial review and also while we’re at perhaps we should not be recruiting soldiers under 25 (and under 18 for that matter).
I'm thinking about this in light of my own most closely related experience- that of discovering one's (homo)sexuality. Bearing in mind I was doing it during the late 1980s - a long time ago, but a time of great fear and hatred of gay men.
The idea that an adolescent would raise the possibility of being trans purely to gain attention strikes me as preposterous. I suppose I can see it being a sort of metaphor - expressing a sense of misalignment which properly belongs elsewhere - but the whole crock of shit about bandwagon-jumping just doesn't strike me as credible.
I suppose that's the main thing that hits me. If one is already feeling fearful and uncertain, and also deeply uncomfortable about oneself and one's connection with the world, the idea that doctors are prodding and poking one's psyche and one's account of its structure, rather than being on one's side and helping one to explore gently and with respect for what is found, is abhorrent. This will leave so many adolescents in fearful isolation, afraid of themselves and of the judgemental and/or prurient fascination with with the rest of the world, including the medical world, is filled.
I'm not talking about shoving puberty blockers down children's necks - though please note that these can have no effect after the horse has bolted - or indeed accepting all adolescents who come forward into the later stages of treatment programmes. However, listening with a gentle ear and trusting what one is hearing is essential - and absolutely not what I am hearing from the report.
In the current British Medical Journal (13 April) there is an opinion piece by Hilary Cass. In it she says
"The fastest growing identity under the trans umbrella is non-binary. There is almost no research on this group, many of whom want a spectrum of treatments falling short of full medical transition."
And
"Medication is binary, but gender expressions are often not."
In the current British Medical Journal (13 April) there is an opinion piece by Hilary Cass. In it she says
"The fastest growing identity under the trans umbrella is non-binary. There is almost no research on this group, many of whom want a spectrum of treatments falling short of full medical transition."
And
"Medication is binary, but gender expressions are often not."
Does she make any valid points here?
Hard to know. Coming back to my usual backstop that, whilst I know a bit about this due to being involved in DSD work, I am no real expert, however:
1. "Non-binary is the fastest growing identity"
- don't know but presumably, there's some straightforward data on this.
2. "Almost no research on this group"
- that is very likely to be true. There is limited research in this whole area and non-binary has not attracted much research interest so she's probably correct here.
3. "...want a spectrum of treatments" / "medication is binary but gender expression are often not"
- All of this is an important point but it's an argument for clinical/individual decision-making with appropriate clinical governance not blanket bans on particular therapies...
I am thinking that non-binary being fastest-growing makes sense, since openly identifying as such, and being analyzed/counted/studied, is so new. I mean, if before you had 10 people openly identifying as such, and now you have 20 coming forward about it, it looks like the number has doubled overnight, even if the number of people who privately identify as NB (or who didn’t have the words to use to describe themselves, etc.) is exactly the same. Am I getting this right?
This ten minute section of the BBC podcast More or Less explains a bit about the evidence evaluation in the systematic reviews commissioned for the Cass report.
I can't escape concluding that Cass's report is probably correct about the quality of available evidence but has failed to give proper weight to the likely consequences of doing nothing in the tiny proportion of trans teenagers where clinicians deemed puberty blockers or cross sex hormones appropriate. I have to say I fear a spike in deaths among trans teenagers as a result of the block on prescribing.
I can't escape concluding that Cass's report is probably correct about the quality of available evidence but has failed to give proper weight to the likely consequences of doing nothing in the tiny proportion of trans teenagers where clinicians deemed puberty blockers or cross sex hormones appropriate. I have to say I fear a spike in deaths among trans teenagers as a result of the block on prescribing.
This.
1000% this.
High quality from More or Less, as always. At this rate, in order to contribute, I'm gonna have to read the report properly. I hadn't realised that Cass had used the York University unit to do systematic reviews for the study. They are excellent, so in that sense it was done properly.
Three things struck me from listening to Cass herself on that podcast
1. She said that "many" of the doctors treating Trans kids were trying to do their best for them. It may have been an inadvertent slip but that's a really worrying thing to say. It unequivocally implies that 'some' were not trying to do their best to care for the patients
2. She said that it was 'almost unique' that there's so little evidence for a treatment being used in children. This is untrue. I know this from my practice. I can point to loads of areas without good evidence; because of the challenges of developing the evidence base. We have to work with this uncertainty, as best we can.
3. There was no acknowledgement at all that there is a risk from not treating. In all medicine, we are weighing one risk against another. It is true that the evidence base in inadequate and that we cannot prove the benefits or know for sure the risks of puberty blockers (and other treatments) in this context. However, we DO know there is a significant risk of not treating. She seemed unwilling to admit that this has to be looked at both ways. To be fair, that may be a feature of how the show was edited but it was a very much unsaid assumption that not treated was risk-free. This is not true.
Yes, point 2 struck me as a wildly optimistic reading of the state of modern medicine. I was reassured by the commissioned systematic reviews - the literature does seem to have been looked at properly which is far from guaranteed in a government process.
Is it possible that Cass comes from areas of medicine with more developed evidence bases and is simply not fully cognisant of the limited evidence in other areas? I note she has a background in studying autism and I wonder if her experience is coloured by the history of abusive "treatments" of autistic people and attempts to impose on us particular "acceptable" behaviours.
Now, in an interview first reported on twitter by TransSafetyNow, Dr. Hillary Cass appears to substantially walk back much of her review, interpretations of that review, and even attempts to brush off her meetings with political appointees in the DeSantis administration who met with her to obtain information they would later attempt to use to ban trans care there. In the interview with UK-based LGBTQ+ organization The Kite Trust, Dr. Hillary Cass is asked if she believes it is OK to prescribe puberty blockers. Her answer is significantly out of alignment with her report:
“In the data the Cass Review examined, the most common age that trans young people were being initially prescribed puberty suppressing hormones was 15. Dr. Cass’s view is that this is too late to have the intended benefits of suppressing the effects of puberty and was caused by the previous NHS policy of requiring a trans young person to be on puberty suppressing hormones for a year before accessing gender affirming hormones. The Cass Review Report recommends that a different approach is needed, with puberty suppressing hormones and gender affirming hormones being available to young people at different ages and developmental stages alongside a wider range of gender affirming healthcare based on individual need.”
Her answer aligns more closely with the current provision of transgender care in many countries, where individual needs and circumstances are prioritized for each patient. However, this is not the tone of the report, which has been used to advocate for significant restrictions and even outright bans. In the United States, the report has been cited by the Heritage Foundation (retweeted) and the Alliance Defending Freedom, organizations that have been actively involved in bans on trans care. In the United Kingdom, the report has even prompted an inquest into adult trans care, raising concerns about its potential impact on this care as well.
Youngsters in Scotland appear to have just lost access to puberty blockers because of the Cass Review
Evidence-based medicine, to me, is a smiling assassin. There are so many difficulties with building up sufficient evidence, if your only standard is a double-blind placebo clinical trial. There needs to be much more sophistication in designing and evaluating ethically justifiable studies which create evidence useful for the future care of people in similar situations in the future. If your only answer is that we will not treat in the absence of your preferred source of evidence, you are an ethical black hole.
One of the difficulties of the Cass review is that the highly polarised discussion around the question of gender dysphoria tends to lead to a focus on trigger issues, or points which one side or the other feels support or undermine their position. It is hard to explore nuance. Added to that there is the woeful underfunding of child and adult mental health services, and the huge amount of information and misinformation around the discussion.
AIUI from reading the Cass report, listening to her interview on More or Less, and reading her responses to the Kite Trust Q&A, the review recognises the difficulty, or maybe impossibility of double blind trials in this field. Studies were evaluated on the basis of methodology, not of outcomes, and with an understanding that double blind trials were probably not going to be available.
On the question of puberty blockers, their efficacy in simply blocking the onset of puberty is recognised. However, in relation to treatment for gender dysphoria the report found (p.20)
the evidence base, particularly in relation to the use of puberty blockers and masculinising/feminising hormones, had already been shown to be weak.
There was, and remains, a lot of misinformation easily accessible online, with opposing sides of the debate pointing to research to justify a position, regardless of the quality of the studies.
further (p.25)
In 2011, the UK trialled the use of puberty blockers in the ‘early intervention study.’
22. Preliminary results from the early intervention study in 2015-2016 did not demonstrate benefit. The results of the study were not formally published until 2020, at which time it showed there was a lack of any positive measurable outcomes.
and again (p. 71)
There were no statistically significant changes reported in gender dysphoria or mental health outcome measures whilst on puberty blockers
Looking at studies on the use of puberty blockers (p. 32)
The systematic review undertaken by the University of York found multiple studies demonstrating that puberty blockers exert their intended effect in suppressing puberty, and also that bone density is compromised during puberty suppression.
82. However, no changes in gender dysphoria or body satisfaction were demonstrated. There was insufficient/inconsistent evidence about the effects of puberty suppression on psychological or psychosocial wellbeing, cognitive development, cardio-metabolic risk or fertility.
83. Moreover, given that the vast majority of young people started on puberty blockers proceed from puberty blockers to masculinising/ feminising hormones, there is no evidence that puberty blockers buy time to think, and some concern that they may change the trajectory of psychosexual and gender identity development.
84. The Review’s letter to NHS England (July 2023) advised that because puberty blockers only have clearly defined benefits in quite narrow circumstances, and because of the potential risks to neurocognitive development, psychosexual development and longer-term bone health, they should only be offered under a research protocol.
In relation to suicide risk (which is discussed extensively, the review found (p.179)
The University of York systematic review found no evidence that puberty blockers improve body image or dysphoria, and very limited evidence for positive mental health outcomes, which without a control group could be due to placebo effect or concomitant psychological support.
This would be less of a problem if it was clear that the use of puberty blockers was entirely reversible, but this is not the case. The review identified concern (stated in p.32, and explored further elsewhere) about
potential risks to neurocognitive development, psychosexual development and longer-term bone health
Surely one wouldn't expect puberty blockers to improve body image or dysphoria, only prevent it getting worse with the onset of puberty. Put another way, a trans boy aged 14 on puberty blockers might feel much as he did at 11, but it seems pretty likely that growing breasts is likely to have a negative effect on his feelings about his body. Maybe I'm lacking in imagination but it's hard to see how you could set up a study to test this is an ethical way.
Yes. Double blind and randomised controlled trial are both out, I think. I’m guessing something like a cohort study or one of the other alternatives would be what is needed.
What Cass has done is give people the confidence to talk about us without talking to us... it has fulfilled the function of giving people permission to exclude us even more.
And I think we need to watch out for that - that we don't end up with cis person talking unto cis person about what another cis person has said without trans people's voices being heard and given the most importance.
I follow a number of trans journalists and trans organisations quite a few of whom I've linked to already. They don't think this report helps them - quite the reverse. They think from their experience that it will endanger trans folk and will cost young lives.
US trans journalist Evan Urquhart is a very measured voice and a good science reporter who specialises in this beat -
The recommendations [of the Cass Review] synthesize a view of medical transition as a bad outcome to be avoided, and a belief that gender dysphoria can be successfully treated non-medically, despite no non-medical interventions being evaluated in any of the series of systematic reviews that found weak evidence in favor of puberty blockers, cross-sex hormones, social transition, and psychosocial support for young people on waiting lists or undergoing medical interventions
If this is so, the report comes from a transphobic place - 'a bad outcome to be avoided' and it does not seem to hold its own suggested treatment approach to its own suggested standards.
It wasn't so long ago that there were highly qualified scientists and doctors coming from homophobic stances (being gay is a bad outcome to be avoided) who were given research funding and taken seriously and did enormous amounts of damage before people listened to what gay people said all along. I remember when people used to come into Dead Horses citing 'ex-gay' and 'reparative therapy' studies.
Letting people who don't have the confidence of LGBT+ people and who appear to hold prejudices about the good of their existence set out to 'do science' about LGBTQ+ folk is never going to be a good idea and where such reports are produced in countries which have deeply transphobic establishments and governments they really shouldn't be placed above trans people's voices and what trans people tell us about their lives and needs.
But it is also true that LGBTQ+ people do not speak with one monolithic voice. The Kite Trust statement, for example, is rather more positive than I would have expected to be honest.
And there are trans people finding that interview interestingly problematic - I've already linked to someone who thinks so.
Trans journalism has been so marginalised in the UK that I've had to build up a list of the trans reporters who cover it here and in the US and trans led organisations who fight for trans rights. I've been following these people for years as well as having people in my own life to ask, so I turn to trans and enby people people who I know or whose track record I know. They are indeed not a monolith and often disagree on things but I can't point to one of those people or organisations who thinks the Cass Review is a good thing. I could post plenty more from trans writers about their criticisms and dismay on Cass beyond what I've posted already but I didn’t want to repeat points already made.
Of the groups I know Scottish Trans were the most conciliatory in their initial response they tried to look for some points of agreement but went on to say they were worried because
In particular, we’re concerned that the review seems to take as its starting point that the best outcome would be that a child or young person doesn’t transition. We totally accept that Dr Hilary Cass does agree that transition may be in some people’s best interests, but the strong impression given by the report is that this should be the last resort
This chimes with what Evan Urquhart says that the report seems to see 'medical transition as a bad outcome to be avoided'
Now bluntly that's a dubious place to be coming from.
As an AuDHD person I would not be happy if there was a big report on us splashed all over the media by someone I recognised as negative about neurodiversity who thought for example, the best outcome was for no ADHD person under 18 to be able to access meds and I would be looking to medical opinion in countries, professional bodies and international bodies where there wasn't significant 'culture wars' or religious conservative capture in the government and institutions to see what they had to say about best practice in medical treatment.
(I also have had the horrible experience of watching institutional capture against trans people happen over a period of years to a reputable UK institution, and to an extent I would never have believed was possible and would have put down to tinfoil-hattery if I hadn't witnessed it, so when trans people tell me they don't accept a report commissioned by an institution in this country is unbiased I believe them)
So I may not physically be capable of being on the barricades with Scottish trans people protesting the Cass Review and Sandyford decisions, but I'm there with them in spirit.
Be careful of citing Stonewall on this, their initial statement went down like a cup of cold sick with most trans people I saw comment on it and they may have paid off their trans researchers
We think this is the wrong decision, and that it will harm trans children and young people.
This decision has been taken within the context where the reality of trans people’s experiences and lives is questioned almost daily in some of the media and some political circles. This makes us worry that the decision has been influenced by that context rather than solely through consideration of the best interests of trans children and young people
Trans journalist Gemma Stone at Transwrites has a lengthy critique of the Cass Review recommendations so I'll quote just her conclusion
Overall the recommendations do not appear to work to benefit the patient but instead work to benefit researchers. Their goals are not to provide timely healthcare, cut down on wait lists, reduce anxieties and improve mental health amongst transgender patients; but rather to organise us into a fashion which makes doing data science easier for them.
If it weren’t for the clear influence of transphobic groups through The Cass Report I would go as far to argue that the rollbacks on trans youth healthcare were incidental. Her single-minded focus here is on generating research and data to be used to either justify or, more likely, oppose trans healthcare.
For Cass and these recommendations; the lives that will be harmed and the children that will die as a result of them are not a bad thing. Cass might even say that its for the greater good; just think of the data that we will generate!
That’s all trans people are throughout The Cass Review. An opportunity to generate data; not human, not suffering, not struggling, not people just wanting to get on with our lives, not people who just want to have our bodily autonomy.
None of that. We are nothing but numbers that, by design, will never show the benefits of transition or be used to improve services — they will only ever show a need for caution and further control over trans lives
And as part of my point that places that are not the virulently transphobic UK are not impressed with this (I've previously cited the Professional Association for Transgender Health Aotearoa who were unimpressed), here is an article from CBC on what Canadian medical professional organisations and doctors they interviewed say about the Cass Review and puberty blockers
Ladha [ Dr. Tehseen Ladha, a pediatrician in Edmonton and assistant professor at the University of Alberta] wondered if the review was "coming from a place of bias."
"I think the framing of it really made it feel as though it was trying to create fear around gender-affirming care," she said.
Donaldson [ Dr. Jake Donaldson, a family physician in Calgary who treats transgender patients] called the systematic review paper and the broader Cass Review "politically motivated
...
Though the review's findings are being used to restrict access to puberty blockers in the U.K., no Canadian medical organization that responded to CBC News said it would change advice here
"As with all areas of medicine, new and emerging evidence is evaluated as it becomes available," said the Canadian Pediatric Society in a statement.
"Current evidence shows puberty blockers to be safe when used appropriately, and they remain an option to be considered within a wider view of the patient's mental and psychosocial health."
Children's Healthcare Canada, which represents children's hospitals, referred to its previous statement in support of evidence-based gender-affirming care for youth, saying: "Our position remains unchanged on the topic
There is also a very measured response from Stonewall.
I’m not sure whether I’d call that measured or a very deliberate attempt to remain calm…
The thing that seems to be justifiably causing anxiety is the language in the executive summary (and I assume the report itself) about turning away from a medicalized treatment for trans youth. This is certainly being read in some quarters as a major departure from current practice - about the first thing I read about the report was a truly nasty piece in the Atlantic by Helen Lewis which seemed to be positively gleeful about the prospect that people are not going to get medical treatment they need (of course she would deny that the treatment is medically necessary, but on the basis of no expertise whatsoever as far as I know).
If there is now a desire to walk back from some of this more categorical language that is all to the good.
That point about "no expertise" is very striking. All manner of anti-trans people are pontificating about it, as if they have the slightest knowledge about gender identity. But now they are proclaiming the end of treatment for trans people, and no doubt anyone with distress about gender. Let the witch hunts begin. And I expect Labour to join in.
I think blanket government decisions about treatment, such as not prescribing puberty blockers, are wrong - this should be clinically led in discussion with the young person but they should also be told about the known pros and cons of treatment and the areas where we don’t know so they can make informed decision.
But I do think further research to develop an evidence base would be a very good idea, provided it is well designed and co-produced with trans people. (We should be clear, just because Cass authored the report, it doesn’t mean she is the person organising or carrying out the research.)
It wouldn’t surprise me, if research shows people on puberty blockers universally go onto cross sex hormones - that we may end up in a place where we say we should offer cross sex hormones at onset of puberty if people have gender distress at that point.
My point being, that services seemed to be only giving puberty blockers at the moment because services were unsure if the young people concerned really wanted to change gender. Whilst cross sex hormones may result in less of the adverse side effects of puberty blockers, because they affect things like muscle and bone growth in the body.
Or to put it more simply, research has the potential to lead to better faster treatment.
I was just having a discussion with a scientist who was confused about the way that Cass handled the available evidence.
I'm not a medic, however I have seen this highly structured way they do medical reviews before. Essentially Randomised Control Trials are the best, but other types of published information is often not even included in the review. If there isn't RCT evidence, they default towards saying there is little/no high quality data rather than delving into everything else. Which isn't necessarily how others do reviews in science. At least part of the problem Cass has been having relates to this.
Of course as others have said here and elsewhere, this is a problem when doing a RCT is difficult or has ethical issues.
According to More or Less, they also included moderate quality studies and their biggest gripe about quality was lack of long term follow up in many studies and a lack study of psychological impact of treatment.
I think you could be right about cross-sex hormones and I have seen Mallory Moore say similar that going directly to them might be better than puberty blockers but can't find the reference
It wouldn’t surprise me, if research shows people on puberty blockers universally go onto cross sex hormones - that we may end up in a place where we say we should offer cross sex hormones at onset of puberty if people have gender distress at that point.
My point being, that services seemed to be only giving puberty blockers at the moment because services were unsure if the young people concerned really wanted to change gender. Whilst cross sex hormones may result in less of the adverse side effects of puberty blockers, because they affect things like muscle and bone growth in the body.
Or to put it more simply, research has the potential to lead to better faster treatment
It doesn't however alter the horror or helplessness people feel now when, because of Cass, that has in reality been put even further away from people (now 18 for cross sex hormones in Scotland) and young people are in danger of being kept without either of these interventions till they have gone through the wrong puberty. After the deluge of transphobia whipped up in the media over the Cass Review anyone who tried to offer going straight to cross-sex hormones to an under-18 would likely be hanged drawn and quartered.
As far as I can see, this wasn't co-produced with trans people in any meaningful sense as far as trans people are concerned and there fairly evidently is not trust for this review among trans people and their organisations to any good level - quite the reverse. It needs to be scrapped and co-produced research carried out by experts most trans people and their organisations have confidence in, but of course in the current transphobic climate it won't be. I think Gemma Stone puts well concerns about what it will actually lead to in terms of research
just think of the data that we will generate!
That’s all trans people are throughout The Cass Review. An opportunity to generate data; not human, not suffering, not struggling, not people just wanting to get on with our lives, not people who just want to have our bodily autonomy.
None of that. We are nothing but numbers that, by design, will never show the benefits of transition or be used to improve services — they will only ever show a need for caution and further control over trans lives
The key is as Scottish Trans says the 'starting point that the best outcome would be that a child or young person doesn’t transition' as Evan Urquhart says Cass seeing ''medical transition as a bad outcome to be avoided". It's unacceptable that somebody with these transphobic views has been put in charge of a major report that affects trans people's treatment on the NHS. Reviews like this must stop using people who don't have the confidence of the community they are meant to serve.
Can anyone explain to me how the SNP and the Scottish Greens have fallen out over the Cass report?
I think broadly the Greens have taken the view that it's ideologically driven and biased in its conclusions. The SNP leadership may well agree (or not) but are terrified of their right wing (Kate Forbes et al). The main falling out, however, was over climate policy, with the SNP rowing back on targets for CO2 reduction, and ultimately HY calculating that he'd get Green support for much of his agenda regardless of Bute House so no longer had to concede anything. He failed to factor in the Greens being a bit pissed off at being stabbed in the back.
Can anyone explain to me how the SNP and the Scottish Greens have fallen out over the Cass report?
In addition to what @Arethosemyfeet said, there is real anger within the Greens that the Scottish Government didn't immediately make a statement that they disagreed with the decision to pause treatment of trans kids at Sandyford. Which was on top of ongoing disquiet that the sections of the programme of government agreed in 2021 regarding improving health care for trans people hadn't advanced. Which is why it was Rainbow Greens who started the petition to call for an EGM.
The New Statesman has a reputation as a famously anti-trans publication - is there some reason to think they've stopped, Doublethink? I wouldn't trust them with an interview on this subject.
I found this transcript from the What the Trans podcast very illuminating. It's of Dr Cal Horton (they/them) who is a
Research Fellow focused on the experiences, rights and well-being of trans children. I’ve been deeply immersed in the literature on this topic for many years, and followed the Cass Review initially with hope, and more recently with a great deal of concern
Unlike Hilary Cass, Cal Horton is an actual expert on the experiences of trans children in the UK and has a lot to say about the Cass Review, and a lot of concerns about its flaws - calling some of its recommendations 'extremely dangerous'
The New Statesman has a reputation as a famously anti-trans publication - is there some reason to think they've stopped, Doublethink? I wouldn't trust them with an interview on this subject.
I think I'd probably trust them to represent Dr Cass's views accurately. I don't think I'd trust their editorializing or critical analysis of her views even the slightest, but if you want to know "what does Dr Cass think about her report", then it's likely to be an accurate reflection of that.
I'm more concerned about the fact that she's not an expert in this field, and where trans/non binary journalists go to mainstream experts in the field outside the UK they don't seem to think much of her review.
Most media coverage of the report has been positive. But by and large that coverage has failed to examine extensive critiques from experts in the US and elsewhere. Research and clinical experts I interviewed explained that the Cass Review has several shortcomings that call into question many of its findings, especially around the quality of research on gender medicine. They also question the credibility and bias underpinning the review. I spoke with four clinical and research experts in pediatric medicine for gender-diverse youth to dive into the criticisms
Carnell (he/they) bulletpointed their article on X as to the critiques that came out of speaking to those experts
1) The Cass Report's bar for evaluating research is too high: "It's really setting a double standard in terms of expectations for evidence."
2) Cass doesn't apply important terminology consistently or accurately: "[Some] terms that might strike a chord with the lay public but don't have any concrete meaning."
3) Cass endorses questionable therapeutic treatment: "At best, gender exploratory therapy is just delaying people's access to the care they need, and at worst, it is conversion therapy... it is associated with harm
4) The Cass Report shows signs of bias: "It's an intentional misapplication of science to deny a minoritized group access to medically necessary evidence-based care.
If you read the full article I've linked to you can see the working and argument behind these points and the quotes from the medical experts.
"an intentional misapplication of science to deny a minoritized group access to medically necessary evidence-based care." as Dr Keuroghlian says, pretty much sums it up for me.
Cass has been saying a lot of things recently in interviews - for obvious reasons her comments have been followed closely and reported by trans researchers who have found some of her comments really ignorant and alarming (especially those to the Scottish Parliament committee and an interview on US public radio). I'd been hoping someone would pull those together in an article to save me linking to every single one but we're not there yet. I would be wary of a polished interview in the New Statesman, given the things she is saying 'in the wild' where the comments are on the record immediately and aren't going into potentially friendly hands for editing.
That was based on a extremely impressionistic sense of what was happening in the UK at the time and I don’t take any pleasure in my prediction coming true.
One thing that strikes me about Cass is that she seems to take the fact that a significant number of AFAB people seeking care related to transition are autistic as prima facie evidence that they're not trans. She assumes that there can't be a correlation between being trans and having a diagnosis of autism, which seems to me to be a poor assumption to make. Setting aside the (real, possibly large) possibilities of differential rates of diagnosis for autism, it seems like a stretch to assume that two conditions that have to do with how someone's brain works must be independent.
Comments
Also, Cass’ own Twitter account follows a number of trans hate organisations and individuals but no trans advocacy groups (eg LGB Alliance, which she unfollowed today once it was spotted, but also Transgender Trend, which is still there).
@Telford per your previous warning here:
This, as a one line assertion, is not acceptable:
I am therefore removing your posting privileges from Epiphanies for a minimum of six weeks.
Doublethink, Admin
[/Admin]
I don't understand the legal position but it sounds like the UKgov could decide that care should not be available to children (private or NHS).
Can they really also decide a fairly arbitrary age date cutoff for adults?
Probably? Healthcare regulation is pretty strict when it wants to be and it would be relatively simple to revoke licensing from any private provider offering gender affirming care to under 25s.
It's complicated. In general, treating someone as 18-25 as not an adult is an absolute no-no in medical law. However, no one has an absolute right to treatment so it would be theoretically possible to frame the regulations this way. I am sure it would be challenged under The Human Rights Act though.
I think it they try and do this someone should it to judicial review and also while we’re at perhaps we should not be recruiting soldiers under 25 (and under 18 for that matter).
The idea that an adolescent would raise the possibility of being trans purely to gain attention strikes me as preposterous. I suppose I can see it being a sort of metaphor - expressing a sense of misalignment which properly belongs elsewhere - but the whole crock of shit about bandwagon-jumping just doesn't strike me as credible.
I suppose that's the main thing that hits me. If one is already feeling fearful and uncertain, and also deeply uncomfortable about oneself and one's connection with the world, the idea that doctors are prodding and poking one's psyche and one's account of its structure, rather than being on one's side and helping one to explore gently and with respect for what is found, is abhorrent. This will leave so many adolescents in fearful isolation, afraid of themselves and of the judgemental and/or prurient fascination with with the rest of the world, including the medical world, is filled.
I'm not talking about shoving puberty blockers down children's necks - though please note that these can have no effect after the horse has bolted - or indeed accepting all adolescents who come forward into the later stages of treatment programmes. However, listening with a gentle ear and trusting what one is hearing is essential - and absolutely not what I am hearing from the report.
"The fastest growing identity under the trans umbrella is non-binary. There is almost no research on this group, many of whom want a spectrum of treatments falling short of full medical transition."
And
"Medication is binary, but gender expressions are often not."
Does she make any valid points here?
Hard to know. Coming back to my usual backstop that, whilst I know a bit about this due to being involved in DSD work, I am no real expert, however:
1. "Non-binary is the fastest growing identity"
- don't know but presumably, there's some straightforward data on this.
2. "Almost no research on this group"
- that is very likely to be true. There is limited research in this whole area and non-binary has not attracted much research interest so she's probably correct here.
3. "...want a spectrum of treatments" / "medication is binary but gender expression are often not"
- All of this is an important point but it's an argument for clinical/individual decision-making with appropriate clinical governance not blanket bans on particular therapies...
Just my thoughts...
AFZ
https://thekitetrust.org.uk/our-statement-in-response-to-the-cass-review-report/
This.
1000% this.
High quality from More or Less, as always. At this rate, in order to contribute, I'm gonna have to read the report properly. I hadn't realised that Cass had used the York University unit to do systematic reviews for the study. They are excellent, so in that sense it was done properly.
Three things struck me from listening to Cass herself on that podcast
1. She said that "many" of the doctors treating Trans kids were trying to do their best for them. It may have been an inadvertent slip but that's a really worrying thing to say. It unequivocally implies that 'some' were not trying to do their best to care for the patients
2. She said that it was 'almost unique' that there's so little evidence for a treatment being used in children. This is untrue. I know this from my practice. I can point to loads of areas without good evidence; because of the challenges of developing the evidence base. We have to work with this uncertainty, as best we can.
3. There was no acknowledgement at all that there is a risk from not treating. In all medicine, we are weighing one risk against another. It is true that the evidence base in inadequate and that we cannot prove the benefits or know for sure the risks of puberty blockers (and other treatments) in this context. However, we DO know there is a significant risk of not treating. She seemed unwilling to admit that this has to be looked at both ways. To be fair, that may be a feature of how the show was edited but it was a very much unsaid assumption that not treated was risk-free. This is not true.
AFZ
Transgender journalist Erin Reed has talked about this here in the Los Angeles Blade
https://www.losangelesblade.com/2024/04/19/anti-trans-british-pediatrician-backpedals-on-her-review-on-hrt/
Youngsters in Scotland appear to have just lost access to puberty blockers because of the Cass Review
https://news.stv.tv/scotland/why-have-scotlands-gender-clinics-paused-prescription-of-puberty-blockers
So it doesn't matter how it's being spun now by Dr Cass, the damage has been done.
AIUI from reading the Cass report, listening to her interview on More or Less, and reading her responses to the Kite Trust Q&A, the review recognises the difficulty, or maybe impossibility of double blind trials in this field. Studies were evaluated on the basis of methodology, not of outcomes, and with an understanding that double blind trials were probably not going to be available.
On the question of puberty blockers, their efficacy in simply blocking the onset of puberty is recognised. However, in relation to treatment for gender dysphoria the report found (p.20) further (p.25) and again (p. 71)
Looking at studies on the use of puberty blockers (p. 32)
In relation to suicide risk (which is discussed extensively, the review found (p.179)
This would be less of a problem if it was clear that the use of puberty blockers was entirely reversible, but this is not the case. The review identified concern (stated in p.32, and explored further elsewhere) about
And I think we need to watch out for that - that we don't end up with cis person talking unto cis person about what another cis person has said without trans people's voices being heard and given the most importance.
I follow a number of trans journalists and trans organisations quite a few of whom I've linked to already. They don't think this report helps them - quite the reverse. They think from their experience that it will endanger trans folk and will cost young lives.
US trans journalist Evan Urquhart is a very measured voice and a good science reporter who specialises in this beat -
https://www.assignedmedia.org/breaking-news/whats-in-the-cass-report
His conclusion is this:
If this is so, the report comes from a transphobic place - 'a bad outcome to be avoided' and it does not seem to hold its own suggested treatment approach to its own suggested standards.
It wasn't so long ago that there were highly qualified scientists and doctors coming from homophobic stances (being gay is a bad outcome to be avoided) who were given research funding and taken seriously and did enormous amounts of damage before people listened to what gay people said all along. I remember when people used to come into Dead Horses citing 'ex-gay' and 'reparative therapy' studies.
Letting people who don't have the confidence of LGBT+ people and who appear to hold prejudices about the good of their existence set out to 'do science' about LGBTQ+ folk is never going to be a good idea and where such reports are produced in countries which have deeply transphobic establishments and governments they really shouldn't be placed above trans people's voices and what trans people tell us about their lives and needs.
Trans journalism has been so marginalised in the UK that I've had to build up a list of the trans reporters who cover it here and in the US and trans led organisations who fight for trans rights. I've been following these people for years as well as having people in my own life to ask, so I turn to trans and enby people people who I know or whose track record I know. They are indeed not a monolith and often disagree on things but I can't point to one of those people or organisations who thinks the Cass Review is a good thing. I could post plenty more from trans writers about their criticisms and dismay on Cass beyond what I've posted already but I didn’t want to repeat points already made.
Of the groups I know Scottish Trans were the most conciliatory in their initial response they tried to look for some points of agreement but went on to say they were worried because
This chimes with what Evan Urquhart says that the report seems to see 'medical transition as a bad outcome to be avoided'
Now bluntly that's a dubious place to be coming from.
As an AuDHD person I would not be happy if there was a big report on us splashed all over the media by someone I recognised as negative about neurodiversity who thought for example, the best outcome was for no ADHD person under 18 to be able to access meds and I would be looking to medical opinion in countries, professional bodies and international bodies where there wasn't significant 'culture wars' or religious conservative capture in the government and institutions to see what they had to say about best practice in medical treatment.
(I also have had the horrible experience of watching institutional capture against trans people happen over a period of years to a reputable UK institution, and to an extent I would never have believed was possible and would have put down to tinfoil-hattery if I hadn't witnessed it, so when trans people tell me they don't accept a report commissioned by an institution in this country is unbiased I believe them)
So I may not physically be capable of being on the barricades with Scottish trans people protesting the Cass Review and Sandyford decisions, but I'm there with them in spirit.
https://twitter.com/Chican3ry/status/1778015643352093124
https://www.scottishtrans.org/response-to-decision-to-pause-referrals-to-paediatric-endocrinology-from-sandyford-young-peoples-gender-service-18-4-24/
Trans journalist Gemma Stone at Transwrites has a lengthy critique of the Cass Review recommendations so I'll quote just her conclusion
https://transwrites.world/the-cass-review-recommendations/
And as part of my point that places that are not the virulently transphobic UK are not impressed with this (I've previously cited the Professional Association for Transgender Health Aotearoa who were unimpressed), here is an article from CBC on what Canadian medical professional organisations and doctors they interviewed say about the Cass Review and puberty blockers
https://www.cbc.ca/news/health/puberty-blockers-review-1.7172920?s=09
I’m not sure whether I’d call that measured or a very deliberate attempt to remain calm…
The thing that seems to be justifiably causing anxiety is the language in the executive summary (and I assume the report itself) about turning away from a medicalized treatment for trans youth. This is certainly being read in some quarters as a major departure from current practice - about the first thing I read about the report was a truly nasty piece in the Atlantic by Helen Lewis which seemed to be positively gleeful about the prospect that people are not going to get medical treatment they need (of course she would deny that the treatment is medically necessary, but on the basis of no expertise whatsoever as far as I know).
If there is now a desire to walk back from some of this more categorical language that is all to the good.
But I do think further research to develop an evidence base would be a very good idea, provided it is well designed and co-produced with trans people. (We should be clear, just because Cass authored the report, it doesn’t mean she is the person organising or carrying out the research.)
It wouldn’t surprise me, if research shows people on puberty blockers universally go onto cross sex hormones - that we may end up in a place where we say we should offer cross sex hormones at onset of puberty if people have gender distress at that point.
My point being, that services seemed to be only giving puberty blockers at the moment because services were unsure if the young people concerned really wanted to change gender. Whilst cross sex hormones may result in less of the adverse side effects of puberty blockers, because they affect things like muscle and bone growth in the body.
Or to put it more simply, research has the potential to lead to better faster treatment.
I'm not a medic, however I have seen this highly structured way they do medical reviews before. Essentially Randomised Control Trials are the best, but other types of published information is often not even included in the review. If there isn't RCT evidence, they default towards saying there is little/no high quality data rather than delving into everything else. Which isn't necessarily how others do reviews in science. At least part of the problem Cass has been having relates to this.
Of course as others have said here and elsewhere, this is a problem when doing a RCT is difficult or has ethical issues.
It doesn't however alter the horror or helplessness people feel now when, because of Cass, that has in reality been put even further away from people (now 18 for cross sex hormones in Scotland) and young people are in danger of being kept without either of these interventions till they have gone through the wrong puberty. After the deluge of transphobia whipped up in the media over the Cass Review anyone who tried to offer going straight to cross-sex hormones to an under-18 would likely be hanged drawn and quartered.
As far as I can see, this wasn't co-produced with trans people in any meaningful sense as far as trans people are concerned and there fairly evidently is not trust for this review among trans people and their organisations to any good level - quite the reverse. It needs to be scrapped and co-produced research carried out by experts most trans people and their organisations have confidence in, but of course in the current transphobic climate it won't be. I think Gemma Stone puts well concerns about what it will actually lead to in terms of research
The key is as Scottish Trans says the 'starting point that the best outcome would be that a child or young person doesn’t transition' as Evan Urquhart says Cass seeing ''medical transition as a bad outcome to be avoided". It's unacceptable that somebody with these transphobic views has been put in charge of a major report that affects trans people's treatment on the NHS. Reviews like this must stop using people who don't have the confidence of the community they are meant to serve.
I think broadly the Greens have taken the view that it's ideologically driven and biased in its conclusions. The SNP leadership may well agree (or not) but are terrified of their right wing (Kate Forbes et al). The main falling out, however, was over climate policy, with the SNP rowing back on targets for CO2 reduction, and ultimately HY calculating that he'd get Green support for much of his agenda regardless of Bute House so no longer had to concede anything. He failed to factor in the Greens being a bit pissed off at being stabbed in the back.
I found this transcript from the What the Trans podcast very illuminating. It's of Dr Cal Horton (they/them) who is a
https://whatthetrans.com/social-transition-puberty-blockers-and-the-cass-review-podcast-transcript/?s=09
Unlike Hilary Cass, Cal Horton is an actual expert on the experiences of trans children in the UK and has a lot to say about the Cass Review, and a lot of concerns about its flaws - calling some of its recommendations 'extremely dangerous'
(One of Cal Horton's articles has been posted already on the thread - here is one of their other articles on social transition)
The importance of child voice in trans health research: a critical review of research on social transition and well-being in trans children
I think I'd probably trust them to represent Dr Cass's views accurately. I don't think I'd trust their editorializing or critical analysis of her views even the slightest, but if you want to know "what does Dr Cass think about her report", then it's likely to be an accurate reflection of that.
The UK’s New Study on Gender Affirming Care Misses the Mark in So Many Ways
Henry Carnell writing for Mother Jones:
Carnell (he/they) bulletpointed their article on X as to the critiques that came out of speaking to those experts
If you read the full article I've linked to you can see the working and argument behind these points and the quotes from the medical experts.
"an intentional misapplication of science to deny a minoritized group access to medically necessary evidence-based care." as Dr Keuroghlian says, pretty much sums it up for me.
Cass has been saying a lot of things recently in interviews - for obvious reasons her comments have been followed closely and reported by trans researchers who have found some of her comments really ignorant and alarming (especially those to the Scottish Parliament committee and an interview on US public radio). I'd been hoping someone would pull those together in an article to save me linking to every single one but we're not there yet. I would be wary of a polished interview in the New Statesman, given the things she is saying 'in the wild' where the comments are on the record immediately and aren't going into potentially friendly hands for editing.
https://forums.shipoffools.com/discussion/comment/361627/#Comment_361627
That was based on a extremely impressionistic sense of what was happening in the UK at the time and I don’t take any pleasure in my prediction coming true.