Carys Moseley, Public Policy Researcher, continues her series analysing the Cass Review and its implications for gender-questioning children. Read part 1.
The second part of Dame Hilary Cass’s review of gender identity services for children and young people deals with how they have been treated.
The ethical question asked is this:
“What is the best way to address, support and manage the whole population of children and young people presenting to services with gender incongruence and/or dysphoria?”
As part of this work, the Cass Review set out to survey treatment frameworks and delivery in other countries. The aim was to learn from good practice elsewhere, if it existed.
The UK led the way internationally in allowing physical ‘treatments’
Cass commissioned research by York University into international guidelines on gender treatments for children and adolescents. The earliest guidelines in this field anywhere in the world were published in 1998 by the Royal College of Psychiatrists. This was for the GIDS, and therefore goes to show how the GIDS and the mental health establishment here in the UK has led the way with allowing any physical ‘treatments’ in the first place. This is important because in recent years the gender-critical movement has publicised the view that the fault mainly lies with the Dutch approach.
In the last few years, a more cautious approach has been taken in Scandinavian countries, France and some parts of Australia.
Inadequacy of guidelines across the world
The University of York found that most guidelines from other countries fell far short of the required standards.
“The guideline appraisal raises serious questions about the reliability of current guidelines. Most guidelines have not followed the international standards for guideline development (AGREE Next Steps Consortium, 2017). Therefore, only the Finnish (2020) and the Swedish (2022) guidelines could be recommended for use in practice.” [Cass Review, 9.24]
It is striking that only a small number of guidelines recommend clinical means of assessing patients’ gender dysphoria. Only Finland assessed patients routinely to see whether they had a history of trauma.
The upshot of all this was that Cass could not recommend adoption of guidelines for assessment for the NHS. Instead, the review’s Clinical Expert Group has been asked to develop an assessment framework.
It is nevertheless concerning that Cass said that clinicians should ‘have no preconceived outcome’. This effectively makes it impossible for therapists to work on the assumption that children’s best interests are served by helping them live in harmony with their biological sex.
Psychological and psychosocial interventions
This is relevant to Cass’s handling of psychological treatment, i.e. therapy, and psychosocial interventions, i.e. a broader approach looking at children in relation to family and social settings.
It is clear from section 11.6 that Cass favours exploratory therapy and means of alleviating a child’s distress, whilst not wanting any therapy that could change the child’s perception of who they are. In other words, therapy that could help a child move away from imagining that they really belong to the opposite sex is not envisaged by Cass as acceptable. This leaves children at the mercy of their own fantasies.
The real problem identified by York University is that there is very little research looking at the outcomes of psychosocial interventions. They found the existing studies to be of low quality. Thus, it’s impossible to provide clear conclusions about how effective such interventions are.
No formal structured programme of therapy at the GIDS
The Cass Review wanted to look at the support available to all children, given that only a small number end up taking puberty blockers and hormones. It proved impossible to get clear information, even though the review organised discussion with GIDS clinicians. Cass complains that there wasn’t a ‘formal structured programme’ for these children. Some had as few as two appointments, others more than a hundred. From this she infers that some children must have been receiving therapy.
The reason for the lack of a formal structure programme of therapy should be obvious – that there is a professional ban on ‘conversion therapy’ which states that mental health professionals are not allowed to have change as a goal. This may well have been interpreted to mean that they are not allowed to set any goals with these clients and their parents.
Does the Cass Review really help families?
It is concerning that nearly all the examples Cass quotes in chapter 11 of people’s ‘lived experiences’ are of people who want to go down the transgender path. I do not therefore think that her recommendation for more help for families of clients should be trusted.
This will open the door for more transgender ideologues and supporters of ‘transition’ to work in the new gender hubs.
How was social transition seen?
Cass talks extensively about the report produced by the Multi Professional Review Group (MPRG).
This group was set up by NHS England after the judicial review brought by Keira Bell and others against the Tavistock, and also the Care Quality Commission report on the GIDS. It was tasked with reviewing cases referred for puberty blockers, to see whether assessment and informed consent had been conducted properly. This MPRG’s report is in Appendix 9 of the Cass Review. It found that children’s history of changing gender legally and socially was very often not investigated by GIDS staff. Staff rarely looked for whether children regretted going down this path. At the same time, the MPRG also blames societal prejudice for children’s fear of talking about their problems, claiming that this drives them to hide them and ‘live in stealth’ (a trans propaganda term) and rush to access puberty blockers.
York University found no clear evidence from published studies on the impact of social transition on children.
Cass notes that early research, e.g. by Canadian therapist Kenneth Zucker, found very few children with gender incongruence continued to suffer from this as adults. She notes that back then in the 1980s few children had already started to live as members of the opposite sex before seeing a therapist.
Unfortunately, Cass does not consider the possible reasons for the rarity of social transition pre-referral. As the transgender movement became more outspoken, and as mental health professional bodies have been increasingly steered by transgender activists, more parents have pushed for their children to be treated as members of the opposite sex. This has not happened spontaneously; it has been part of the strategy of the transgender movement. The result of this has been to increase the demand for puberty blockers.
Too much tolerance for social transition for adolescents
Cass distinguishes between the supposed needs of children and adolescents.
She advises greater caution for children. She thinks there is only weak evidence for the effect of social transition in adolescence. The papers reviewed are not clear enough, but it seems that social transition before puberty means those children are less likely to detransition later. One obvious reason not mentioned would be that they lack sufficient memory of life acknowledging their biological sex; detransition later would feel more intimidating.
Cass’s neutral stance coupled with her overt child-centred approach leads at times to bizarre assumptions, e.g.
“It is important to ensure that the voice of the child is heard in any decision making and that parents are not unconsciously influencing the child’s gender expression.”
This could easily be understood to mean that parents should not ‘unconsciously’ influence a child to express him or herself as a member of his or her own sex. Given her disapproval of ‘unconscious’ influence by parents upon their own children, she is hardly likely to approve of conscious attempts by parents to influence children.
We must ask what exactly does Cass think parents are for? Is it not influencing your children part and parcel of being a parent?
Cass is also extremely unwise in recommending ‘partial transition’ as a way of helping children cope with stress. How is it ever good to encourage children to lie and deceive?
Supposed benefits of puberty blockers disproven
Cass is generally better on the problems with so-called ‘medical’ approaches to gender dysphoria, no doubt because she is a medical doctor not a mental health professional. She highlights how the list of supposed benefits of puberty blockers has gotten long over time:
“As explained above, when the Dutch gender clinic first started using puberty blockers to pause development in the early stages of puberty, it was hoped that this would lead to a better cosmetic outcome for those who went on to medical transition and would also aid diagnosis by buying more time for exploration. Since then, other proposed benefits have been suggested, including improving dysphoria and body image, and improving broader aspects of mental health and wellbeing.” [Cass Review, 14.22]
She reminds us that puberty blockers do not buy time to think through gender distress.
“These data suggest that puberty blockers are not buying time to think, given that the vast majority of those who start puberty suppression continue to masculinising/feminising hormones, particularly if they start earlier in puberty. It was on the basis of this finding that the High Court in Bell vs Tavistock suggested that children/ young people would need to understand the consequences of a full transition pathway in order to consent to treatment with puberty blockers ([2020] EWHC 3274 (Admin)).”
They do not reduce gender dysphoria or improve body satisfaction.
“Only two moderate quality studies looked at gender dysphoria and body satisfaction; the original Dutch protocol (de Vries et al., 2011b) and the UK early intervention study (Carmichael et al., 2021). Neither reported any change before or after receiving puberty suppression.” [Cass Review: 14:26]
Risks of puberty blockers
It is also good that Cass makes it clear that puberty blockers can have certain risks, and that all young people wanting to use them – and parents who want their children to use them – should be made aware of those risks.
In the first instance, they don’t just block puberty, they actually block people’s understanding of their own puberty:
“Blocking this experience means that young people have to understand their identity and sexuality based only on their discomfort about puberty and a sense of their gender identity developed at an early stage of the pubertal process. Therefore, there is no way of knowing whether the normal trajectory of the sexual and gender identity may be permanently altered.” [Cass Review. 14:37]
Cass warns that the maturation of the brain could be derailed for a time or permanently by puberty blockers.
Finally, she stresses their potential effect on bone density and height gain, stressing the need for long-term follow-up studies to find out whether bones recover their health fully in adulthood.
Claimed risk of suicide puts pressure on families
Cass’s review also addresses the often-repeated claim that limiting access to puberty blockers could lead to children committing suicide. She heard from people who said that the spreading of this claim could pressurise families to get treatment from private gender clinics.
She was also contacted by GPs who had been pressured to prescribe puberty blockers for fear that the teenagers under their care would be at risk of suicide.
Research and restrict hormones
Regarding cross-sex hormones, the reviews commissioned by Cass prompted a similar level of caution. The outcomes of both puberty blockers and cross-sex hormones were required by the Cass Review to be evaluated by a research programme. She insisted that children who consent to participate in this research should be followed up into adulthood.
It is good to know that Cass recommends ‘extreme caution’ in providing cross-sex hormones even to 16- and 17-year-olds, even though they are already available to them. She insisted on a ‘clinical rationale’ for providing them for under-18s.
Cass’s caution is insufficient
It is good to see that the Cass Review found through its commissioned research that studies on so-called ‘medical’ treatments were inadequate.
This no doubt parallels its findings that the guidelines available internationally are also deeply inadequate.
Her caution is welcome. However, it has led to continuance of puberty blockers and cross-sex hormones in more research. The problem is therefore deeper. It seems Cass is unwilling to accept the obvious truth that puberty is simply not a disease, and that therapy should in fact aim to enable children and adolescents to live in harmony with their biological sex.
This in turn will impact how Cass handles Service models, which will be the topic of the next article.
Read part 3
