Hilary Cass’s proposals are largely based on common sense. She must reject anti-trans bias with the same clarity | Freddy McConnell
TThe long-awaited Cass review of gender identity services (Guide) for children and young people is finally here, and people with a wide variety of views seem to be welcoming it. In more civilized, evidence-based times, when transness was accepted as just one example of human variation, this outcome might do her credit: appropriate for an assessment of clinical services by an expert physician.
However, we do not live in such times. Instead, Britain has fallen to 15th in Europe’s LGBT+ equality rankings in recent years (in 2016: Great Britain is in third place) and wash emphasized by the Council of Europe alongside Hungary, Turkey and Russia as a state where LGBT+ rights are under attack by political figures, including governments. We are also experiencing a sharp increase in hate crimes against transgender people UN report directly attributes to “the toxic nature of the public debate around sexual orientation and gender identity.”
This context is important for understanding the rather confusing reception of the Cass review. Judging from the reporting in the British right-wing media, where transgender equality is most vociferously and regularly opposed, you might be convinced that Hilary Cass agrees with them and them alone: on the front page of the Daily Mail she was praised as “a voice of common sense”. ”; the Times claimed that the report outright rejected the use of puberty blockers. However, this is not the case.
Cass is critical of Gids’ long waiting lists. Because I have been involuntarily delving into this subject for almost ten years, I can report that the trans community wholeheartedly agrees with this and has been raising the alarm for years. Cass criticizes the lack of broader mental health care, including treatment for eating disorders. The community agrees, as does anyone who knows anything about NHS mental health care. Cass cites the lack of awareness and assessment of autism. Once again, the community—well aware of and unafraid of our tendency toward neurodivergence—agrees. Cass advocates more and more local services from Guide. It’s no surprise that the trans community agrees. Cass laments the lack of a peer-reviewed scientific basis for trans care. Right there with you, Doc (although there is a lot of research that you have decided to exclude).
I could go on, but you get the idea. It is also difficult to disagree about the key words – read clearly and in good faith. Care for trans youth that is “unhurried, holistic, therapeutic, safe and effective”? What’s not to like about it? This is just what prospective patients, patients and their parents and caregivers have been asking for all along.
In reality, the problem has never been disagreement about how to care for trans children and youth. On the contrary, individuals who are actually motivated to create such services have been effectively sidelined by an overwhelmingly more powerful coalition of politicians, journalists and even health professionals motivated by an anti-trans ideology – a necessity to claim and in some way to ‘prove’ in some other way, to the exclusion of all other possibilities, that transgender people like me do not actually exist. And that’s why we don’t spend the first eighteen years of our lives as children.
What many trans adults like me fear is that Cass has fallen into the trap of reflection and therefore given credence to anti-trans prejudice.
Take puberty blockers, for example. Young people hoping to be prescribed this previously uncontroversial puberty delayer, including those I have had direct contact with, usually have to wait so long for appointments that they leave Gids before the conversation even begins. In 2022, 378 children and young people were eligible to be prescribed blockers by the NHS, a relatively small number by any measure. The same applies to masculinizing or feminizing hormones for young people under the age of 18. The review shows that this sounds like it was previously common. In reality, such a move would only be considered for someone aged 16 to 18 and is even rarer.
There are also more insidious examples. Cass refers to doctors who feel unable to express their concerns about Gids’ slow and inadequate service. Justin Webb wondered on the Today program whether this legitimate criticism of a failing service could be attributed to the fear of being accused of ‘transphobia’. Cass agrees to a point, but then focuses on reconciliation, saying that “whatever the reason” for doctors’ concerns, she believes everyone was sincerely trying to do their best for their patients.
The inability to add context reflects a lack of context in the report itself: which paints a picture of doctors who all want the best for their young patients, and have been let down by a lack of evidence. That is not a complete picture. Take Dr David Bell, the psychiatrist behind a critical report on the Tavistock centre, and who has welcomed the Cass review. Bell is often portrayed as a moderate critic of Gids and yet has argued that trans children do not exist in nature, but have been inventedand that cases of gender dysphoria in children can be explained by confusion caused by sexuality, confusion caused by neurodiversity, confusion caused by abuse, trauma or mental health issues, but, crucially, never by that child, alone or among other factors, being transgender. He has described “top surgery” – an abbreviation trans men use for a masculinizing double mastectomy – as “bizarre Orwellian news speak”.
He has described gender confirmation surgery for adults in Frankenstein terms, lamenting people like me as “sterile and lifelong patients, many of whom face catastrophic complications.” I don’t really want to dignify this claim with a serious rebuttal, so suffice it to say that regret rates for gender confirmation surgeries consistently hover around a whopping 1%.
Bell’s views are echoed by Julie Bindel, who in response to the review says the idea of trans children is a “crazy fallacy”, calls trans adults “fanatics in the grip of a crazy doctrine”, compares us to Jimmy Savile, and says thank you Cass for the “validation” her report provides. Bindel and Bell are both part of the Clinical Advisory Network on Sex and Gender, a gender-critical pressure group.
These views fundamentally undermine transgender identity and the legal basis on which our rights to things like dignity, privacy and medical care are also protected. Failure to identify such extreme opinions and pushing them back in an evaluation aimed at improving care for gender-questioning children and youth is inexcusable. Giving Cass the benefit of the doubt, perhaps simply stating that trans children and adults exist, seemed too basic – but in the clinical and cultural context in which we operate, it remains vital.
If the Cass review were held under a black light, we would see the fingerprints of anti-trans ideology. I don’t believe Cass shares this way of thinking, I think she believes in evidence-based healthcare and that trans children exist. However, the fact that her review is so heavily influenced by bias is a critical failure that she herself must acknowledge.
With her work being used, as it will be, to perpetuate a wider hostile environment towards transgender people in Britain, the young people she has tried to help will understandably feel betrayed. I take this opportunity to plead with her team to keep this in mind as she calls for a similar review of services for 17 to 25 year olds–year olds and possibly beyond. Trans adults need holistic, safe care too (doesn’t everyone?), but our clinics are also in a terrible state, with up to five years waiting for a first appointment. Now there are also reviews about us – about us, but no one knows to what extent of us – which could become Trojan horses for those who want to withdraw or perhaps eradicate affirmative trans care from the NHS altogether.
Dr. Cass, reconciliation can get you through this short-term discomfort in the media spotlight, but please remember: it is not your healthcare, your rights, or your everyday dignity that they are trying to take away.