Cass Report makes ‘highly questionable recommendations’

5 April 2022

Christian Concern policy researcher Dr Carys Moseley comments on Dame Hilary Cass’ interim report into the Gender Identity Development Service for children and adolescents.

Recently, paediatrician Dame Hilary Cass published her Interim Report into the Gender Identity Development Service for Children and Adolescents. The report has been praised in the press and by gender-critical campaigners. However, there is a question as to whether the report really gets to the heart of the problems.

Pressure on doctors acknowledged

First, the good news.

The report does find that doctors are pressured into favouring a transgender-affirmative approach to children. This was widely reported in the press.

The report also repeatedly states that there are major gaps in the evidence about puberty blockers and cross-sex hormones. This repeats what was already known. What the Cass Report also says is that many doctors experience pressure to support the use of puberty blockers, and that the evidence base on these matters is also inadequate worldwide. Surely this lack of solid evidence in their favour should make the medical profession reluctant to use them.

In fact, three expert reports used in the case of Nigel and Sally Rowe go even further by reporting on the long-term damaging physical consequences not only of using puberty blockers, but of overly affirming transgenderism in young children. This alone should be enough to make the medical profession sit up and listen.

Concerns about affirmative model

The Cass Report conveys major concerns about the dominance of a model of care based on affirming children’s self-identification as transgendered. It cites a complaint by NHS England’s Multi-Professional Report Group:

“From the point of entry to GIDS there appears to be predominantly an affirmative, non-exploratory approach, often driven by child and parent expectations and the extent of social transition that has developed due to the delay in service provision.”

The lack of a standardised approach for assessing children’s mental health or neurological development, together with lack of consistent documentation, was also strongly criticised.

What the Cass Report does not say is that the affirmative model reigns because the Memorandum of Understanding on Conversion Therapy is in place. In this respect, the report falls short of the criticism already made by former GIDS clinician Dr Marcus Evans in August 2020.

Because the Memorandum is in place, clinicians fear that they may be accused of conversion therapy if they do not affirm a child’s acquired gender. Indeed, Evans claimed back then that the affirmative model had already been adopted by nearly all children’s services in the UK, by which he must have meant CAMHS. There is no mention of this in the Cass Report.

The practical outworkings of the affirmative model were strongly criticised by Evans, namely activists creating a climate of fear whereby experienced clinicians could no longer help patients. He gave the examples of Kenneth Zucker in Canada and James Caspian in the UK. Cass has nothing to say about any of this.

Inadequate follow-up of patients

Also reported was the inadequacy of long-term follow-up data on children and teenagers who have been through gender identity clinics. This was true whatever their outcomes, whether they had had physical ‘treatments’, gone onto adult gender identity clinics, or regretted their gender reassignment and de-transitioned.

Part of the problem was the paucity of research on sexual, cognitive and wider development of these children.

Better evidence required on trans regret

It is very important that the Interim Report calls for better evidence on why some people regret gender reassignment and detransition. This is to be welcomed. However, it is disappointing that no practical recommendation is given on this matter. What is needed is something like a statutory requirement for collecting data on this matter. In addition, doctors and healthcare professionals need to come together to learn about the problems regretters and de-transitioners face. At present there is no official group dedicated to such work. This needs to change.

Now, the bad news. The Interim Report makes numerous highly questionable recommendations. There are also fundamental problems of moral and philosophical coherence inherent to the entire report. These problems could have far-reaching consequences.

Cass Report ignores the biological definition of sex

The Cass Report uses the following definition of sex:

“Referring to the biological aspects of an individual as determined by their anatomy, which is produced by their chromosomes, hormones and their interactions; generally male or female; something that is assigned at birth.”

In doing this the report completely ignores the biological and legal definition of sex as based on chromosomes, recognised by Justice Ormerod in the Corbett v Corbett case (1973) and again in the judgment in favour of Maya Forstater last year. How can responsible paediatrics – medical care of children – be conducted when an untruth such as ‘sex is assigned at birth’ is peddled? Midwives do not ‘assign sex’, they recognise it.

No recommendation on puberty blockers

Due to the huge gaps in the evidence, the Cass Report makes no advice on using puberty blockers or cross-sex hormones. However, it promises that “recommendations will be developed as our research programme progresses.” The problem here is that record-keeping by the GIDS has been deemed inadequate for a long time. Therefore, any evidence will have to be new. This means that more children will have to receive these experimental and unethical ‘treatments’ before the Cass Report can make recommendations.

Is it not time that action was taken based on what is already known, which is that these drugs can cause irreversible damage?

Cass Report wants endocrinologists to be more involved

The report calls for paediatric endocrinologists to be more involved with gender-confused children.

“Paediatric endocrinologists should become active partners in the decision making process leading up to referral for hormone treatment by participating in the multidisciplinary team meeting where children being considered for hormone treatment are discussed.”

Is this a good idea? What is already known about paediatric endocrinologists’ views on the rights and wrongs of giving children puberty blockers and hormones? Doesn’t making them more involved risk attracting into the profession those who would like to see more children given these inappropriate treatments?

At section 3.8 the Cass Report says this:

“From 2011, early administration of puberty blockers was started in England under a research protocol, which partially paralleled the Dutch Approach (the Early Intervention Study). From 2014, this protocol was adopted by GIDS as routine clinical practice. Results of the Early Intervention Study were published in December 2021.”

In fact, referrals of children to the GIDS shot up from 2011 onwards, and also then from 2015 onwards. Could it be that this is due to puberty blockers being made available at an earlier stage and then more widely? Did the very availability of puberty blockers lead to more demand for them?

Notion of consent left unchallenged

Even more concerning is that the Cass Report assumes that children can consent to puberty blockers:

“It is particularly important to demonstrate that consent under this circumstance has been fully informed and to follow GMC guidance by keeping an accurate record of the exchange of information leading to a decision in order to inform their future care and to help explain and justify the clinician’s decisions and actions.”

The GIDS had already promised to improve record-keeping for children’s consent to puberty blockers. This means the Cass Report’s recommendations on this are neither new nor original.

The problem here is that whilst it is true that record-keeping needs to improve drastically, there is no moral discussion about whether or not children can consent to such experimental, life-changing ‘treatments’. If an independent report cannot rise above the ideas fed into the NHS by LGBT activists, what good is it?

Cass Report ‘recommends’ creation of regional gender hubs

Despite all these serious problems, the Cass Report recommends that regional hubs for gender-confused children should be created. The reason is that the GIDS cannot cope with the volume of cases. Once again, however, this turns out not to be a truly independent or original recommendation. Section 6.9 lets slip that this idea came from NHS England. Sadly this suggests that regional hubs – more GIDS chaos everywhere – may be a fait accompli.

The important question is how will suitable staff be found for the proposed hubs? Many GIDS clinicians have already resigned. Will they come back into the hubs? Won’t the split between those favouring sex-based approaches and those favouring gender-affirmative approaches be perpetuated in the hubs, unless the problem is addressed now?

Evidence from psychotherapy not considered

There is virtually no mention of the evidence-base for talking therapy to help people resolve their gender dysphoria while coming to terms with their real sex and/or identity. This is a major problem. It is not enough to say that evidence must be gathered to understand de-transition. What is needed is far better evidence-gathering at earlier stages. This used to exist, as evidenced by older textbooks and academic papers on psychotherapy, which actually pinpointed causes of gender dysphoria (such as parents not wanting a child of a particular sex, peer abuse, etc.) This evidence was published back in the 1990s by Kenneth Zucker and colleagues from the Toronto gender identity clinic. That sort of evidence-gathering is unfashionable because it shows up dysfunctional family problems as being at the root of childhood gender dysphoria.

The Cass Report occasionally cites recent evidence from gender identity clinics for children, but not systematically so. It promises a literature report in the near future. This is bizarre given that normally a literature report is the first task completed in a research project, so as not to duplicate previous work. We need to ask whether there was a studious avoidance of the older evidence on family dysfunction. The Cass Report’s silence on the Memorandum of Understanding on Conversion Therapy lies at the heart of this avoidance of psychotherapy.

Is puberty normal?

The report makes numerous value statements which sound reassuring but are in reality rather ambiguous. For example, this statement about what success would look like:

“My measure of success for this Report will be that this group of children and young people receive timely, appropriate and excellent care, not just from specialists but from every healthcare professional they encounter as they take the difficult journey from childhood to adulthood.” [p. 13]

What exactly is ‘appropriate and excellent care’? For it has to be said that nowhere does the Interim Report criticise puberty blockers as not being real medicine at all. Nowhere does it ever say that puberty is not a disease, but a normal part of human development that should never be pathologised. Where is the vision of true healthcare in this area?

Beware false optimism due to conversion therapy ban double U-turn

It is true that the Cass Review was cited by the government as a reason for not pressing ahead with the ban on ‘LGBT conversion therapy’. This is known from the document leaked to ITV News last week. The video of the leak shows what was said:

“HMG commissioned research has shown that the evidence-base for further legislative measures on conversion therapy is weak. The interim findings of the Cass Review said evidence on the appropriate management of children and young people with gender dysphoria is inconclusive both nationally and internationally.”

However, all this came only a few days after the Prime Minister celebrated gender reassignment:

“When people want to make the transition in their lives, they should be treated with maximum possible generosity and respect.

“And we have systems in this country that allow it and have done for a long time. We should be very proud of it.”

The press focussed on the rest of his statement which was that the biological differences between men and women matter. This was because he was positioning himself in opposition to Keir Starmer. The reality is that the new gender hubs recommended by NHS England and Cass will be gender identity clinics in all but name.

Why the Interim Report is inadequate

It is obvious that the Interim Report is deeply inadequate. It is not as independent or original as some might like to think. It is important to say here that the reason that regional hubs are being proposed is to sidestep the disputes that would arise if integration into local CAMHS were to be proposed. For this would be to admit that gender dysphoria is a mental health condition, not an identity. It is not an accident that regional hubs are really the idea of NHS England, which is a signatory of the Memorandum of Understanding on Conversion Therapy.

Some (a minority of) psychotherapists would agree, but in reality, these have already resigned from GIDS. Certainly now, due to the professional ban on ‘conversion therapy’ in the UK, there is no official training available that would treat gender dysphoria as a mental health problem. The regional hubs will be staffed by people whose training has been narrowly ideological thanks to the Memorandum. More of the same is not what is needed. On the contrary what is needed is to get to the root of the problem and look at the philosophy that has underpinned the GIDS from its inception in 1989. Clinicians and NHS managers must say why the GIDS has always allowed for children to grow up to live as members of the opposite sex. They must give an account of why puberty has been treated as a disease for some children for so long.

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