The anti-trans frenzy is peaking in England this week following the release of a much-anticipated review by Dr. Hillary Cass on transgender care. Many anticipated that the report would serve as a pretext to ban transgender care in England, and it appears to have been crafted to provide just such a rationale. Nations already enacting restrictive laws against transgender individuals will likely use it as justification for further discrimination. In the United States, far-right Christian nationalist groups, including Heritage Foundation (retweeted), Association of Christian Schools International, and the Alliance Defending Freedom, have cited it to support anti-trans legislation they are involved in drafting or lobbying. The Cass Review is an exercise in politics with predetermined conclusions, not science and medicine, and health authorities worldwide should reject its findings.
For those unaware of the Cass Review, and the general situation in England for transgender people, that’s understandable. Transgender people have been struggling to raise alarms there for some time after wait lists to obtain gender affirming care have ballooned in excess of 5 years, which is often prohibitive in obtaining care. After a series of political attacks on transgender people and rising anti-trans sentiment in the country, the NHS commissioned a review and tapped Dr. Hillary Cass, a pediatrician whose list of follows on social media include extremist anti-trans sources such as Transgender Trend (which argues, as is obvious, that being transgender is a “trend”), the LGB Alliance (a LGB group that believes in “dropping the T,” or transgender people), and Graham Linehan (an anti-trans activist and comedian), along with many other noted anti-trans voices. From the outset, there were concerns about her ability to conduct a study neutrally.
Over the course of the review, these concerns intensified. On one occasion, Cass met privately with medical board members selected by Governor Ron DeSantis in Florida to ban transgender care through the Florida Medical Board and appeared to collaborate via email. This only came to light during a contentious trial that revealed the board’s intention to ban transgender care from the outset, prior to any review. Cass’s involvement in what was essentially a predetermined strike by DeSantis against transgender people raised red flags. On another occasion, her team enlisted a researcher with a history of promoting conversion therapy as a viable option for transgender individuals to handle reviews of evidence on which the report would be based.
Now that the final report is out, it is evident that it was crafted with a predetermined conclusion in mind. The review, highly susceptible to subjectivity, disregarded the body of research on transgender care as not “high quality,” a subjective judgment that cannot be trusted as politically unbiased given prior concerns. The Cass Review lends credence to claims that being transgender is “contagious” and that it can influence others around them, claims that have been debunked by dozens of medical organizations. It cites Youtube propagandists that share material from “Gays Against Groomers,” a Republican-aligned anti-transgender organization in the United States. It fearmongers that being transgender might be caused by depression, anxiety, and autism, claims that the American Psychological Association, the world’s largest psychological organization, has rejected in a recent policy resolution. It asserts that rates of detransition or desistance are high, citing outdated studies from conversion therapists like Ken Zucker, who reportedly used methods such as withholding wrongly gendered toys in an attempt to “treat” transgender youth. These purportedly high rates of “detransition” or “desistance” are challenged not only by external fact checks but also data within Cass’ own review.
The review cites heavily studies that have been misleadingly used to claim that being trans may be caused by being friends with other trans people. For instance, immediately after making social contagion claims, it references a study of “2,772 adolescents” that purportedly links the question “I wish to be of the opposite sex” to “poor self-concept” and “same-sex attraction.” Cass uses this to essentialy claim that many transgender individuals do not know who they are, suggesting that trans individuals may actually just be gay people influenced into being trans by being friends with other trans people—a claim without evidence, often perpetuated by those opposed to trans care. It is important to note that the study Cass cites does not concern trans people; rather, it focuses on cisgender individuals who occasionally wish they were the opposite sex for any reason, including tomboys, feminine gay boys, people experiencing sexism, and more. In that particular study, 19% of participants responded this way, a rate magnitudes higher than the often-estimated 0.5% of transgender individuals. Nevertheless, Cass includes this study as though it applies to transgender individuals, whose desire is not “occasional” but enduring.
It is important to note that the Cass Review contains very little new data and evidence. Any statements it makes are based on the same level of evidence that every major medical organization in the United States, along with some of the largest mental health societies in the world and professional associations of transgender health, have determined to support transgender care. If its claims differ from those institutions, it’s because reviewers made choices to view the evidence around transgender care negatively. For instance, Cornell University has reviewed over 51 of these studies and found that gender transition improves the well-being of transgender people. Interestingly, the scant data the Cass Review did commission on its own actually turned out to support gender-affirming care for trans youth.
For instance, the review on page 168 notes that in a study of patients in England, fewer than 10 transgender youth detransitioned or desisted. This could be seen as evidence of careful transgender care, supported by other research indicating that 97.5% of transgender youth are stable in their gender identity five years later. However, Dr. Cass interprets this as evidence that puberty blockers cause transgender youth to feel locked into their gender identity, despite their role in giving both the youth and their care providers time to ensure that transition is appropriate. No evidence was presented that transgender youth feel this way, and the review certainly had the opportunity to ask the question of the youth it interviewed. It is conceivable that if a larger number of youth were desisting or detransitioning, Cass and others with similar views would argue that clinicians are failing to correctly identify transgender individuals and would use this as justification to block care. They have created a situation where the evidence will be interpreted negatively no matter what it shows.
The Cass Review, like the Florida review, was not conducted through a rigorous scientific process by the field’s leading experts. Instead, it seems designed to manufacture a consensus, using science as a guise for politics—there can be no other explanation for the decisions made in the document. This is evident when, after reviewing the same evidence, virtually every major medical organization in the United States strongly supports the evidence base for transgender care. Meanwhile, in Germany, another report was announced last month, which judged the exact same evidence strong enough to justify keeping transgender care for youth accessible. Announced in a press conference, this report involved collaboration among 27 professional medical organizations and 2 patient organizations. The press conference announcing the guidelines states that “not providing treatment can do harm” and that “These are not merely our personal observations; there are several longitudinal studies that now also show that there are some improvements in the medium to long term for these young people who are supported in such a fashion.” This full report is expected to be published soon after a four-week review, at which point it will likely become the official recommendations of the Association of the Scientific Medical Societies in Germany.
Transgender individuals in England deserve far better than sham reports concocted to justify escalating crackdowns on their care. They merit more than being subjected to DeSantis-style politics that weaponize fear over their very existence and their fundamental right to bodily autonomy. They are owed individualized care, collaboratively done with their doctors and caregivers, that is meticulously tailored to meet their unique medical needs. Documents like the Cass Review fall drastically short of protecting transgender youth, and instead serve to shield the sensibilities of those who tirelessly seek to justify their control over the lives of transgender people.
