Cass Review: A Child Dressed in Rags?

I discuss Dr Hilary Cass’ Preliminary Report in an earlier blog. The Final Report of her Independent review of gender identity services for children and young people was released in April 2024. It runs to almost 300 pages including a glossary, references, and twelve appendices.

Dr Cass comes over as a very kind and friendly person – good qualities in a doctor. But where clarity of expression and even forthrightness are needed, in her attempt to be fair to everyone we’re left up in the air.

What it means to be trans
The Foreword opens with these words: ‘This Review is not about defining what it means to be trans.’ But if the Review can’t or won’t even do that, on what basis is it written? This doubt is reinforced by another statement: ‘The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.’

This assumes a priori an entity called gender-related distress, which needs to be ‘managed’, but what is gender-related distress? It’s merely an idea, feeling, sense, belief, or delusion that the child or young person was born in the ‘wrong’ body. No one is born in the wrong body.

Furthermore, the interventions being considered in this situation are alterations to a physically healthy child or young person’s body by hormonal manipulation and even surgery – an approach fraught with risk and which could be considered unethical or even criminal. The object is not to correct an obvious or objectively verifiable abnormality, but to create an abnormal physical state with the aim of alleviating the child or young person’s unhappiness. Such interventions, by their very nature, are and cannot but be harmful. The problem is that a declaration of gender dysphoria (gender-related distress) is taken at its face value rather than being seen for what it is.

Evidence – or the lack of it
In her efforts to help these children and young people, Dr Cass is fixated on ‘evidence’, or rather the lack of it. This is how she puts it in wordy, cliché-ridden statements:

I have been disappointed by the lack of evidence on the long-term impact of taking hormones from an early age; research has let us all down, most importantly you. However, we cannot expect you to make life-changing decisions in a vacuum without being able to weigh their risks and benefits now and in the long-term, and we have to build the evidence-base with good studies going forward. (Presumably, she doesn’t mean bad studies going backward.)

And her proposed remedy?

The first step for the NHS is to expand capacity, offer wider interventions, upskill the broader workforce, take an individualised, personal approach to care, and put in place the mechanisms to collect the data needed for quality improvement and research.

This sounds all very well, but how can we acquire this kind of evidence? It would mean doing a clinical trial, but this would be unethical as well as impractical as I have explained previously: ‘One would have to take a group of young people wishing to transition and treat them with drugs and perhaps surgery; take a comparable group and not treat them – placebo treatment would be impossible; follow-up both groups for some years or even decades; and then compare the results. It cannot be overemphasised that using hormones and surgery in so-called transgender people will produce irreversible life-changing bodily alterations. And all this to treat a delusion!’

We don’t need evidence: we need common sense. Even if a trial were to be attempted, how could a pre-pubertal child or teenager give informed consent? You can’t give informed consent to sign away something you’ve never experienced. Puberty is an essential stage in the physical, mental, and sexual development of humans. Normal puberty won’t necessarily resume if you stop the blocker – you’ll just be some months or years older in a child’s body. And if you then go on to cross-sex hormones you won’t magically become a person of the opposite sex. It’s not as if this a benign treatment. Indeed, Dr Cass notes, ‘endocrine (hormonal) interventions have potential risks to neurocognitive development, psychosexual development, and longer-term bone health.’ She might have added that they can also result in impaired or absent fertility.

Sense at last?
Dr Cass does at least say some sensible things, even if long-windedly:

Although a diagnosis of gender dysphoria has been seen as necessary for initiating medical treatment, it is not reliably predictive of whether that young person will have longstanding gender incongruence in the future, or whether medical intervention will be the best option for them.

Is medical intervention ever the best option? There seem to be doubts:

Focus on the use of puberty blockers for managing gender-related distress has overshadowed the possibility that other evidence-based treatments may be more effective. The intent of psychosocial intervention is not to change the person’s perception of who they are, but to work with them to explore their concerns and experiences and help alleviate their distress regardless of whether or not the young person subsequently proceeds on a medical pathway.

I would go further and say the intent of psychosocial intervention is to help alleviate their distress and accept their reality.

Verbosity
Abounding in verbosity, much of the Review makes for tedious reading. I’ll give a few more examples:

Governance needs to be put in place to oversee implementation of the required changes and provide system-wide leadership. (The required changes need to be implemented.)

The welfare of the child or young person must remain paramount in all considerations. At the centre of the Review is a group of children and young people who are seeking support, and our responsibility is to devise a model of care that will safeguard their best interests and set each one of them on a pathway that helps them thrive as an individual. (The welfare of the child or young person seeking support is paramount. Our responsibility is to safeguard their best interests.)

The Review has to be grounded in a thorough examination of the most robust existing evidence. (The Review is based on the best available evidence.)

Conclusion
The Conclusion of the Review is presented in nine numbered paragraphs. I’ll comment on just two of them:

16.34 In considering endocrine interventions, the large number of unknowns regarding the risks/benefits in any one individual and the lack of robust information to help them make decisions present a major problem in obtaining informed consent.

Perhaps Dr Cass is trying to say, ‘In considering endocrine interventions, obtaining informed consent is a major problem.’ Indeed it is. Obtaining informed consent is impossible, and that’s why, apart from other reasons, these interventions should not be used.

16.39 The option to provide masculinising/feminising hormones from age 16 is available, but the Review would recommend an extremely cautious clinical approach.

Whether the approach is merely cautious or extremely (!) cautious, this is meaningless. Either one provides these hormones or one doesn’t. And in view of paragraph 16.34 quoted above, the only sensible conclusion, I’ll repeat, is that these interventions should not be used.

Text © Gabriel Symonds