Public policy researcher Carys Moseley starts her series looking at the findings of the Cass Review
The much-publicised Cass Review of gender identity services for children and young people has produced a great deal of research to gain a better picture of the field.
In a short series of articles, I shall attempt to show some of the more significant findings as part of a series assessing the value of the Cass Review.
The aims of the Cass Review
Dame Hilary Cass says her review aims to make recommendations to ensure high standards of care for children with gender dysphoria, or who are ‘questioning their gender identity’.
The review tried to understand the growth in referrals of children, particularly girls, to the GIDS. Research conducted for the review aims to show how these children should be treated by the NHS.
At the very core of the Cass Review was the intention not only to collect existing evidence from the UK and internationally, but to improve the evidence to help health professionals make better decisions regarding these children.
Hundred-fold increase in prevalence of gender dysphoria in under-18s
Appendix 5 of the Cass Review contains a summary of a study based on the Clinical Practice Research Datalink, which contains anonymised patient data from GP surgeries across the UK.
This sample of general practices found that between 2009 and 2021 the prevalence of gender dysphoria in children up to 18 increased over a hundred-fold.
Cass also found that there were two phases of increase: 2009-2014, and 2015 onwards. In the latter phase the increase was faster among girls. Crucially, however, the available records did not say whether the gender they recorded had already been changed.
This raises questions as to whether the increase in girls is masking a greater parallel increase in boys being referred than has hitherto been admitted. This has to do with the practice of changing a patient’s NHS number if he or she wants to change gender.
The problem with changing patients’ NHS numbers
The Cass Review interviewed healthcare professionals about the policy and practice around changing patients’ NHS numbers if they wanted to change gender. NHS guidance states that a patient who asks to change gender must be given a new NHS number.
As Cass explains, this makes it more difficult to pinpoint the long-term outcomes for these patients. The review heard of children and young people lost to follow-up because of this. Others were said to have turned up at emergency departments, yet staff had no record of their history of safeguarding problems because of the change of NHS number.
Cass heard from the Multi Professional Review Group (discussed in Appendix 9) that some children referred to GIDS had already changed their NHS numbers by the time of their appointments. These professionals claimed that the GIDS mostly didn’t investigate these children’s life histories to see whether they had problems or regretted ‘transition’.
Increase in referrals similar to other countries
The Cass Review helpfully reveals that the increase in the number of referrals has had a parallel in other countries; there was a marked increase from 2014 onwards elsewhere too.
This should enable further investigation and collaboration on the international level. Could some other countries have better records than those in the UK?
Co-occurring mental health problems
Cass had commissioned a systematic review of studies in the field, published this year in the British Medical Journal.
Nearly half of the studies found reported depression and anxiety among patients, with a fifth reporting other mental health problems. Overall, children and young people referred to gender clinics had higher rates of anxiety, eating disorders and depression than other children.
Research from Finland (5.31) showed younger cohorts had greater mental health needs than previous ones. In other words, the situation of children with gender dysphoria is worse now than it was for the previous generation of children with this condition.
Cass did not find solid evidence for biological causes for gender dysphoria in children.
Children with tics
The Cass Review’s commissioned research also reports on evidence of a close link between children having tics and having gender problems.
One study from 2023 found that four in ten patients with functional tics identified as transgender or non-binary. They also were much more likely to suffer from depression, anxiety and social phobia.
Tics were more common among girls than boys, often triggered by having watched videos showing people exhibiting such behaviour on social media. This echoes the widely held view that the rise in GIDS referrals may partly be due to social contagion.
Body Dysmorphic Disorder
The review found a link with Body Dysmorphic Disorder, which is more common among girls than boys and more likely to develop after puberty.
A lot of these teenagers are on the autistic spectrum with the majority feeling suicidal. Cass expressed particular concern that BDD is frequently not diagnosed or not diagnosed properly.
It is, however, reassuring to know that there are good outcomes for teenagers suffering from BBD, such as types of therapy and medication. Of particular interest is the fact that some teenagers with BDD are unhappy with their sexual characteristics, but that appropriate treatment can lead to some feeling less ill at ease as a member of their sex.
Autistic spectrum and ADHD
It is well known that a significant minority of children referred to the GIDS have been on the autistic spectrum or had ADHD.
The Cass review’s range of commissioned research helps put this alongside these other mental health problems. Particularly poignant is the following observation on how difficult these teenagers find it to explain to others what they are experiencing:
“Difficulties with interoception (making sense of what is going on in their bodies) and alexithymia (recognising and expressing their emotions) can sometimes make it hard for these young people to express how they are feeling about their internal sensations, their gender identity and their sexual identity.”
It appears that this sub-population of children and adolescents are vulnerable due to communication difficulties to misinterpreting their problems as stemming from an unaffirmed transgender identity.
Adverse Childhood Experiences
The systematic review of studies commissioned by Cass admits that there aren’t very many that report on Adverse Childhood Experiences.
I think this shows insufficient curiosity by researchers in the field. ACEs were found nevertheless to be more common among referred children. The figures are shocking:
“combined neglect or abuse (11-67%)
physical abuse (15-20%)
sexual abuse (5-19%)
emotional abuse (14%)
maternal mental illness or substance abuse (53% and 49%)
paternal mental illness or substance abuse (38%
exposure to domestic violence (23-25%)
death or permanent hospitalisation of parent (8-19%)
loss of parent through abandonment resulting in adoption (1-8%), foster care (1-12%) or children’s home placement (0.5 – 5%).”
Sadly, due to there not being enough studies of this, Cass concluded that it isn’t possible to say how the number has changed over time.
Finally, it is good to see that Cass references the study of the earliest children referred to the GIDS between 1989 and 2001, by its founder Domenico Di Ceglie.
She draws attention to the fact that 42% of children had lost one or both parents, and 15% had experienced physical abuse. More than a quarter had been in social care. Nearly half lived with a single parent. I think it is telling that after Di Ceglie left in 2009, no more research on ACEs among GIDS patients was published, nor was there a study of the children referred between 2001 and 2009.
Decline of children’s mental health since 1999
The Cass Review’s findings aren’t comforting for anyone to read. One the one hand, they show that rates of suicide have not been higher for children and adolescents referred to GIDS. On the other, they show that the rise in referrals has run parallel with the overwhelming evidence for the decline of children’s mental health since 1999, among both boys and girls.
There has been a marked increase in self-harm, anxiety and depression among teenage girls and young women. Eating disorders and self-harm have gone up since the Covid-19 pandemic.
Increase in referrals since puberty blockers became available
The data is clear that the number of children referred has increased since puberty blockers became available off-label in 2014.
Cass does not ask whether this has also been related to parental connivance and manipulation.
The limitations of the Cass Review
Point vii of the Review Scope (set out in the Terms of Reference in Appendix 1) states that the review would explore the reasons for the increase in GIDS referrals, particularly of girls. In practice, this shifts the focus towards referrals since 2009 when the increase started. Cass does refer briefly to the important research by Domenico Di Ceglie.
The reason such historical research is of value is that it gives us a better picture of the change that has happened. There were fewer children than ten per year in the very early years (Section 2.4). This suggests the idea of an early or even inherent transgender identity in some children was much rarer in the past before the increase from 2009 onwards.
At the same time, there is other early research that Cass does not cite which could have helped understand this earlier period contrasted with the time since 2009. There is the textbook by Kenneth Zucker and Susan Bradley from 1996, which for many years was the most comprehensive textbook on psychological causes and treatments for these children.
Second, the two earliest pieces of research on adult transsexuals in the UK also contain retrospective evidence of the childhood of transsexual adults in the UK.
There is the MD thesis of John Randell, the founder of Charing Cross Hospital Gender Identity Clinic, published in 1960. I discuss this in the fourth chapter of The New Normal. There is also the study of around 200 patients at that clinic between 1978 and 1981 by clinical psychologist Bryan Tully, as part of his PhD completed in 1987. This was published as a book in 1988.
These show that most adults who cross-dressed or presented themselves to the gender clinic had not cross-dressed as children or felt as children that they belonged to the opposite sex. Tully also found that adults with disabilities and behaviour problems were being put through ‘sex-change’ treatment and questioned the appropriateness of this approach.
So why has the number of girls referred increased?
Cass enquires whether greater societal acceptance of transgender identities has led to the increase. She says this cannot explain it, because it does not explain the switch from male to female prevalence or the increase in ‘complex presentations’, i.e. children who have other problems.
However, this is where some more digging into the trans activism that has affected the NHS and schools would have helped. First GIRES, then Mermaids have long been active since the 1990s. Most people aren’t aware of this. There is a need to know when these groups started going into schools. For the increase in referrals dates back to 2009/2010, the time when the Equality Act 2010 was being pushed through Parliament. This is the time when the concept of the transexual child was codified in law.
Adult gender clinics refused to co-operate with follow-up study on children
This may explain why Appendix 4 of the Cass Review reveals that seven out of eight of the adult gender identity clinics in England refused to co-operate with the University of York in carrying out a study of the medium and long-term outcomes for children referred to GIDS. Appendix 4 of the review states what the study had intended to do, tabulating the excuses given by the clinics for not co-operating, together with the responses from the University of York.
This meant that the adult gender clinics did not help with providing better understanding of the children and adolescents referred to the GIDS.
This is why health minister Victoria Atkins criticised the culture of secrecy around gender services in the NHS. She expressed her disgust and anger in Parliament on Monday about this. The NHS has now ordered a review of adult gender services as well. However, most of the NHS trusts that refused to co-operate have now bowed to pressure and agreed to share their data.
The importance of understanding the patients
The huge amount of work done by the Cass Review to synthesise a lot of the existing evidence on children with gender dysphoria is very welcome, despite some key shortcomings.
The wider and deeper we look at the evidence, the more we see that the underlying problems are psychological and behavioural.
We see that they have to do with the heart of human nature, but we also see how many adults have turned their backs on all children’s need to grow up to live in harmony with their biological natures as male and female.
We see the sheer obstructiveness of activists in the gender clinics.
Ultimately we see what the deliberate dechristianisation of society and how that has affected healthcare and medicine, actually looks like. We see the rotten fruits of an ‘anti-Christendom’, human rights approach to children and healthcare.
Read part 2
