The Cass review of gender identity services marks a return to reason and evidence – it must be defended

as the dust settles Hilary Cass’s report – the most comprehensive and thorough evidence-based evaluation of the treatment of children suffering from gender stress that has ever been undertaken – it is clear that her findings support the serious concerns that I and many others have expressed. Central to this was the lack of a good quality evidence base to support claims about the effectiveness of young people being prescribed puberty blockers or following a medical pathway to transition. I and many other physicians were concerned about the risks of long-term adverse effects from early medical intervention. Cass has had to speak out already against the spread of misinformation about her review, and a Labor MP has acknowledged her Parliament “may have misled”. when you refer to it. The review must be protected from misrepresentation.

The policy of “affirmation” – that is, quickly agreeing with a child that he or she is the wrong gender – was an inappropriate clinical position advanced by influential activist groups and some senior staff at the Gender Identity Development Service (Guide), resulting in a distortion of the clinical domain. Research shows that without medical intervention, a majority of children will quit – that is, change their minds.

The many complex issues faced by these young people went unnoticed when viewed simplistically through the prism of gender. Cass helpfully calls this “diagnostic overshadowing.” Thus, children suffered three times: because not all their problems were properly addressed; by being put on a path for which there is insufficient evidence and for which there is a significant risk of harm; and finally, because children not unreasonably believed that all their problems would disappear once they went through the transition. I don’t think it is possible for a child in an acute state of torment to think about the consequences of a future medical transition. Children have difficulty imagining themselves in an adult sexual body.

Some claim that few puberty blockers were prescribed. Cass cites figures showing that around 30% of Guide patients in England discharged between April 2018 and December 31, 2022 were referred to the endocrinology service, of whom around 80% were prescribed puberty blockers; the proportion was higher for older children. But these figures are likely an underestimate as 70% of children were transferred to adult care at the age of 17 and their records were lost because they were unfortunately not followed up. This is one of Gids’ most serious governance problems – also specifically addressed by the judges in Keira Bell v Tavistock. Six adult gender clinics refused to cooperate and provide data to Cass. However, because they were under significant pressure, they did so now admitted.

It is often claimed that puberty blockers were not experimental because their use has been around for a long time. They have been used in precocious puberty (for example when a child, sometimes as a result of a pituitary abnormality, develops secondary sexual characteristics before the age of eight) and in the treatment of prostate cancer. But before 2011, they had not been prescribed by Guide to children experiencing gender dysphoria. The lack of long-term evidence underlies the NHS’s decision to end their gender dysphoria. routine prescription for children as a treatment for gender dysphoria – that is, for those whose bodies were physically healthy.

Guide clinicians’ attempts to raise concerns about protection and medical management were ignored or worse.The then medical director heard concerns but took no action; ditto the Speak up Guardian and the trust management of the Tavistock and Portman NHS Foundation. I was a senior consultant psychiatrist, and it was in my role as staff representative on the Trust Board of Governors that a large number of the Guide clinicians approached me with their serious concerns. This formed the basis for the report that was presented to the board in 2018. The trust then carried out a ‘review’ of Gids, based solely on interviews with employees. The CEO said the review found no “deficiencies in the service’s overall approach to responding to the needs of the young people and families accessing the support”. I was threatened with disciplinary action. When child protection leader Sonia Appleby raised her concerns before the trust’s review, the trust threatened her with an investigation; and his reaction, like a Labor court later confirmed, damaged her professional reputation and hindered her patronage work.

Characterizing a child as “being transgender” is harmful because it excludes the situation and also implies that this is a unitary condition for which there is a unitary “treatment”. It is much more useful to have one description: that the child is suffering from issues related to gender/sexuality, and this should be carefully explored in terms of the story of their life, the presence of other issues such as autism, depression, history of abuse and trauma, and confusion about sexuality. As the Cass report notes, research shows that a large proportion of these children are attracted to the same sex. and many suffer from homophobia. Concerned gay and lesbian doctors have said this experiencing homophobia in the service, and those staff worked in a “climate of fear”.

It is misleading to suggest that I and others who have raised these concerns are hostile to transgender people. We believe they should be able to live their lives free from discrimination, and we want them to receive safe, evidence-based holistic health care. What we have opposed is the hasty placing of children on a potentially harmful medical pathway for which there is significant evidence of a risk of harm. We emphasized the need to spend significant time investigating this complex and multifaceted clinical presentation before taking such steps. Young people and doctors routinely speak of “upper surgery” and “lower surgery,” terms that seriously undermine these major surgical procedures such as double mastectomy, removal of pelvic organs, and the creation of an engineered penis or vagina. These procedures carry very serious risks, such as urinary incontinence, vaginal atrophy, cardiovascular complications, and many others that we are just beginning to learn about. There is a very serious risk of sexual dysfunction and infertility.

There are no reliable studies (for children or adults) that can support claims about low levels of regret. The frequently cited studies (e.g. Bustos et al. 2021) have been criticized for their use insufficient and incorrect data. The crucial problem here is the fact that children and young people who were put on a medical program were not followed up. Research shows that the majority of detransitioners, a growing population who have to deal with the consequences of following a medical program, do not do so. back to the clinics because they are very afraid of the consequences. The fact that there are no dedicated NHS services for people transitioning is symptomatic of the lack of NHS care for this group. Many live very lonely and isolated lives.

Those who say that a child was “born in the wrong body” and who have neglected the protection of children bear a very heavy responsibility. Parents have been asked “Do you want a happy little girl or a dead boy?” Cass notes that rates of suicidality are similar to rates among non-trans-identified youth referred to child and adolescent mental health services (CAMHS). The NHS’s head of suicide prevention, Prof. Sir Louis Appleby, said “Invoking suicide in this debate is wrong and potentially harmful.”

It has been suggested that the Cass report sought to ‘appease’ various interests, with the implication that those who promoted these potentially harmful treatments have been sidelined. But in reality, it is those of us who have raised these concerns who have been silenced by trans rights activists who have had significant success in shutting down the debate, including preventing conferences from going ahead. Doctors and scientists have said they have been deterred from pursuing research in this area by a climate of fear, and that they have faced great personal costs for speaking out, ranging from intimidation to professional risks and even, like Cass has experienced safety problems in public.

The pendulum is already swinging towards a reaffirmation of rationality. Cass’s achievement is that he has given that pendulum enormously greater momentum. In the years to come, we will look back with disbelief and horror at the damage done to children.

• David Bell is a retired psychiatrist and former president of the British Psychoanalytic Society

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