It will be harder than ever for younger people to access gender-affirming care in Britain following the release of the Cass Review.
The Cass Review – a review examining children’s gender-related treatment in the NHS, published on Monday – has been warmly welcomed by anti-trans factions, the Tories, and Labour’s shadow health secretary, Wes Streeting. However, it represents the latest attack on the freedom and autonomy of trans youth to choose their own paths.
The review recommends that the NHS adopts a comprehensive approach to assessment and mental health care, with no provision for puberty blockers without undergoing clinical trials, and extremely limited access to cross-sex hormones before the age of 18. The requirement for two clinicians to attend each appointment was cited as one of the reasons for the years-long waiting lists at Gender Identity Development Services (GIDS), making gender-affirming care already inaccessible for the vast majority of young trans individuals. The Cass Review proposes an even more referral-intensive process, which may exacerbate the existing barriers of referrals, potentially driving trans youth away from the NHS altogether.
The therapy-based approach encourages patients to explore other causes for their gender-related distress, often citing eating disorders, neurodivergence, or societal acceptance (as if being trans is a fad at school) – all of which must be thoroughly explored before gender transition can be considered.
The conversion therapy model is inherently harmful, but the framework conveniently suggests that transition may be considered only after exhausting all other options. Cass acknowledges that some young people may require medical intervention, but by assuming that the majority do not and should be discouraged at all costs, Cass appears to endorse mass-scale conversion practices.
Even the review’s premise is flawed. “We have no good evidence on the long-term outcomes of interventions to manage gender-related distress,” it proclaims in the introduction. However, Cass claims that cross-sex hormones and puberty blockers are more effective at reducing anxiety than reported, partly because she has chosen to exclude the majority of potentially significant studies from her analysis.
But there is a deeper underlying fallacy. Since 2019, the World Health Organization has recognized that “transgender-related and gender-diverse identities are not mental health disorders, and classifying them as such can result in significant stigma.” Despite this, Dr. Hilary Cass opts to resurrect the concept of gender dysphoria, arguing that transition can only benefit from addressing mental health issues.
However, transition is not a mental health issue; it requires medical assistance from healthcare professionals (comparable to pregnancy in those who cannot conceive naturally). While studies show that trans boys who have access to transition have extremely low rates of regret when properly assessed by clinical psychologists and allowed to commence testosterone, there will never be a foolproof method to guarantee that a trans boy who begins treatment as an adolescent will not later regret this decision as an adult. The error lies in recommending that the individual refrain from using testosterone until this can be conclusively proven.
The Cass Review suggests that the NHS will eventually identify the precise combination of sexual orientation, childhood interests, and pornography consumption habits that accurately predict whether an individual will identify as a trans man or cis woman. Cass is fixated on expanding data collection in this manner. Cass calls on the government to mandate this same infringement of patient privacy after being “stymied” in her attempts to compel adult gender clinics to surrender patient records. Additionally, completing coursework will become a requirement for receiving puberty blockers from the NHS.
Wes Streeting fully supports The Cass Review, referring to its findings as “scandalous” and criticizing NHS trusts that did not cooperate with the inquiry, as seen on The Sun’s YouTube channel. pic.twitter.com/kI1EYyvjTT
— j (@jrc1921) April 10, 2024
The needs of clinicians, who are hesitant to treat this patient cohort due to politicization of their healthcare, and parents, whose consent is required for a treatment plan to proceed, are prioritized. The needs of the patients themselves, who Cass consistently misgenders and whose desires she repeatedly and explicitly dismisses in her report, are relegated to a lower priority. It seems never to occur to Cass that some transfeminine individuals have no desire for vaginoplasty, some nonbinary individuals may desire surgery, hormones, or both, and some trans individuals prefer physical interventions before social transition, often for their safety.
Despite Cass’s proposed assessment model allowing parents to provide a history of their child’s gender, there is no discussion on the fact that over 40% of trans individuals in the UK experience abuse from family members. Cass also recommends, likely influenced by anti-trans parental groups, that youth gender services integrate care for individuals aged 17 to 25, essentially infantilizing the 75% of adult gender clinic patients in this age group. It remains unclear whether GIDS’s practice of requiring 17-year-olds to bring their parents to appointments, a practice unheard of in any other branch of medicine, will be extended to patients in their mid-twenties.
Most egregiously, the individuals for whom this service is intended are an afterthought. Cass notes that it is disheartening that many young people felt compelled to lie to GIDS counselors about their mental health, yet she offers no solutions to rebuild trust in the new service. Being treated as a clinical intervention serves to introduce the NHS into the lives of transgender toddlers and primary school-age children, requiring parents to prevent them from “going stealth” (i.e., fully living in their chosen gender) due to the pressure it may later exert on healthcare professionals to prescribe puberty blockers.
Cass opposes a medical system that places too much responsibility on practitioners to mitigate potential regret, leading clinicians to adhere to a misguided professional ethic rather than prioritizing the patient sitting before them. Cass believes it would be unethical to adhere to the informed consent model that the vast majority of trans individuals support.
The recommendations in the report constitute a complete assault on the lives and dignity of trans children and young adults, dismissing the belief that “doctors know best” and posing a threat to medical orthodoxy. While legislation may render trans healthcare illegal, trans individuals will continue to resist and fight back.
