Say what you like about the Conservative government; it is very good at commissioning reviews that suit its political agenda. From its review of racial and ethnic disparities in the UK, which was heavily criticised for claiming that there hardly were any, to its review of supply chain finance and Greensill Capital in government, which was dubbed a whitewash and contributed to David Cameron’s teflon reputation, it keeps on getting what it wants. The Cass review into gender identity services for children and young people served by NHS England is, sadly, more of the same.
The Cass review
In presenting the review, its author, Dr Hilary Cass, made reference to what she called “a stormy social discourse” surrounding the subject it addresses. Labour’s Wes Streeting said, “Children’s healthcare should always be led by evidence and children’s welfare, free from culture wars”. Few would disagree. Trans people, certainly, don’t want to be treated as a political football. The difficulty is that, as this article will show, the review is not politically neutral and falls well short of the evidence-based approach one might have hoped for.
This is not the first time that the Conservatives have commissioned a review into issues affecting trans people. The 2016 Transgender Equality report, which also looked at aspects of healthcare and treatment protocols, was quietly shelved when its findings proved politically inconvenient. Conservative MP Maria Miller, who led the review team in that instance, proceeded to speak out about her concerns and the need for urgent action shortly before this new, more specific review was commissioned.
Flawed methodology
The methodology for the Cass review was established by a team from the University of York including Tilly Langdon, who has previously been involved in promoting Gender Exploratory Therapy – an approach which, despite its neutral-sounding name, discourages children from identifying as trans and has been likened to conversion therapy. Her approach included setting a very high bar for evidence to be considered in the review, ruling out 100 of the existing 103 studies into the use of puberty blockers and hormones to treat trans children.
The reason given for excluding all these studies was that they did not incorporate a double blind approach – in other words, they did not involve giving puberty blockers to some patients and placebos to others. This might sound like a reasonable objection on the face of it – until one considers that puberty is a dramatic physical and psychological process, and people can easily tell when it’s happening to them, so a double blind simply wouldn’t work in practice.
Internal inconsistencies and poor grasp of the basics
The Cass review called for more research and, again, few would disagree with this. The suggestion that treatment should be withheld in the process, however, is not neutral. It presupposes that the harm done by puberty blockers (demineralisation of bones, which is usually temporary in the short-term treatment recommended and is similar to what occurs in pregnancy) is more severe than the harm done to a trans child by going through the wrong sort of puberty. The latter is linked to high rates of self-harm and suicidal ideation, together with the need, in many cases, for extensive surgical procedures.
Confusingly, the review states that children taking puberty blockers showed “no changes in gender dysphoria or body satisfaction”, which suggests that the author didn’t actually understand what puberty blockers do at all. They don’t make children feel better – they just delay a process that makes them feel worse.
This is one of several oddities in a report that lacks internal consistency. It states that there is no established definition of social transition, for instance, and does not offer one, but goes on to talk about it as if there were. It also talks about autistic ‘girls’ identifying as trans in increasing numbers, treating this as mysterious and as cause for concern, despite acknowledging elsewhere that more and more girls are being diagnosed as autistic, so one would expect more diagnoses to be present within any subsection of the young female-assigned population.
No capacity to consent until 25?
Perhaps the most worrying of the review’s conclusions – which should concern people far beyond the trans community – is the suggestion that as far as NHS treatment is concerned, trans people should be treated as children until they are 25. The rational for this is that 25 is the age when (on average) the brain stops developing. As any neurologist will tell you, the brain is in fact never static, and within ten years or so of that age, it begins to shrink. Deciding who has the capacity to make decisions based on brain age could have unintended consequences for the likes of Cass (64).
That aside, what would setting the age of true adulthood at 25 mean for everybody else? If we couldn’t allow people to consent to medical treatment at 24, should we ask them to risk dying for us? If not, then at a stroke we could lose a quarter of our armed forces. Likewise, we would have to give serious thought to what to do about a third of parents who might not be considered competent to look after their newborn children.
And then there are issues like contraception. Right-wingers have long contended, on one pretext or another, that teenage girls shouldn’t have the right to take the pill without their parents’ consent. This is where the review’s suggestion starts to look less like a double standard and more like the thin end of a very nasty wedge.
Children as a political football
Responding to the review, Victims and Safeguarding Minister Laura Farras told Sky News that the review’s findings would lead to a “fundamental change of direction” whereby young people would no longer find themselves “funnelled down an irreversible pathway” toward hormonal and surgical transition. There has been an outpouring of support for the suggestion that gender-questioning children should, first and foremost, receive counselling.
The thing is, that doesn’t represent a change of direction at all. They always did receive counselling. Many did decide that transition wasn’t right for them – demonstrating clearly that the system was working. The ones who remained in need of help, however, rightly received it – until the NHS abruptly stopped prescribing puberty blockers following the Bell v Tavistock judicial review, and failed to change that decision despite the Tavistock’s successful appeal.
Children’s wellbeing is indeed at stake here, but that includes the wellbeing of children who are actually trans. Far from taking the matter out of politics, the review – and Rishi Sunak’s subsequent praise of it – has put it centre-stage. Some readers will remember the climate of homophobia that suffused the run-up to the 1997 general election, when the Conservative Party, desperate as it is now, brought out the “They’re coming for your children” rhetoric in a last-ditch effort to panic people into voting for it. This review – whose final report has been awaited for some time – feels like an attempt at the same thing.
What vulnerable young patients need is indeed neutral and evidence-based care. But the Cass review – which provides very little evidence in support of its own recommendations – won’t give them that. What it may provide is a little bit of oxygen for a flagging government. Children deserve better than this.
