The Failure of the Cass Review

In a recent comment Tildeb championed an interim report of an inquiry on the best way to serve the needs of trans children in the UK.   Almost everything I read said the report only got one thing correct in that much more needed to be done to open more treatment facilities for trans people and that the national health system needed to do more.    Then because it seems the thing the report wanted to push was anti-trans propaganda the report tried to say the best treatment would be to deny that kids are trans and would grow out of it and should be treated with affirmative therapy which is another way of saying conversion therapy.   Affirmative therapy is saying kids should be treated and forced to see that they are in the right body to match their gender and to accept that is who / what they are.    Forget that trans nonsense, just like being gay is a fad, it is just rebelling against your parents and kids will grow out of it.   All kids experiment and then they grow up, no one is gay because god did not make mistakes.  It is all the same thing of denying it and forcing kids to never admit it.   It is something most of the modern world has grown beyond and only the traditionalists refusing to admit times have changed in a way they dislike still cling to.    For those wanting to know how bias and slanted the report was here is a breakdown of it.   Hugs

The Failure of the Cass Review

This morning people who care about trans kids were reacting in utter dismay to hearing the Secretary of State for Health use the Cass interim review to justify the need to exclude trans people from a ban on conversion therapy.

I’ll link the lovely Olly Alexander linking to a clip of our Health Secretary using Cass to call for conversion therapy for trans kids – see here

Despite evidence that conversion therapy on trans children is particularly harmful, with research showing “For transgender adults who recalled gender identity conversion efforts before age 10 years, exposure was significantly associated with an increase in the lifetime odds of suicide attempts”.

For days now, MPs and commentators have cited the Cass review, in justification of the need for conversion therapy specifically for trans kids.

Of course they do not say conversion therapy for trans kids. They talk of ‘children suffering from gender confusion or gender distress’, they talk of ‘exploratory therapy. They talk of ‘unintended consequences, by which some clearly mean, they fear the law would stop them conducting conversion therapy on trans kids.

Those who want to conduct conversion therapy on trans kids hide behind a new favourite term of ‘exploratory therapy’. It is a friendly sounding rebrand of conversion therapy. It is focused on probing, delaying, questioning and at its heart, problematising trans identities. There is nothing wrong with being trans. Some kids are trans – get over it.

The same people who actually want conversion therapy for trans kids, are trying to create confusion on the meaning of affirmative therapy. They are trying to paint affirmation as a bad thing, as something forced. They are wrong and they know it. Affirmation is about meeting a person where they are, about listening to what they need. It has space for as much talk therapy on identity as a person wants. Without coercion. Without compulsion. Without considering trans or cis as a bad outcome.

Parents of trans kids are today VERY upset. People had put their faith in Cass to help our kids.

Personally, I feel something else other than upset. I feel cross at myself for not speaking up earlier.

Back when the Cass review was first announced, I had serious concerns. Concerns that have continued to mount.

There was Cass’ personal twitter following of a load of highly transphobic groups & no trans people.

There was the Cass review’s initial refusal to even say the word trans kids, in a review aimed primarily at helping trans kids.

There was the lack of any trans people on the Cass team, and the fact that the Cass team explicitly asked for people with no knowledge or experience of trans-ness, as though that was a preferable.

The fact there was no oversight group consisting of respected trans health experts and trans community leaders.

Back at the start I felt deep in my gut that this would go badly and would not serve the needs of trans kids. I seriously considered trying to get parents of trans kids together to stage a boycott until there was some proper trans representation. I didn’t for four major reasons. For one, the biggest reason, I was so tired & out of time and energy. For two, I wanted to give optimism a go – just cos everything else always fails trans kids in the UK, why couldn’t this be different – here we had a paediatrician reviewing trans kids healthcare, something I’d been asking for for years, maybe this time would be different. For three, I hoped having formal peer reviewed publications to feed into the process would make a difference (spoiler – it didn’t – the Cass team had my peer reviewed research article on the UK service from the highly respected international journal International Trans Health and didn’t even bother citing it). For four, I didn’t think things could really get much worse for trans kids in the UK, so I didn’t see how much real harm it could do.

Obviously I was very wrong. I noted my initial reaction to the pathologisation embedded in the Cass report.

The Cass interim report is now being cited everywhere to justify the need for conversion therapy for trans kids. It is being cited to deny inclusion of trans people of any age from a ban on conversion therapy.

The red flags about the Cass process meanwhile continue to grow.

I’ve been interviewed, found Cass on the face of it an empathetic listener who keeps her cards close to her chest.

Other parents of trans kids have been interviewed, again felt Cass had listened with kindness.

Many are deeply upset about the Cass interim report and the way it has encouraged further bigotry.

The Cass interim report couldn’t even take a decision on whether being trans is pathological. It couldn’t even take a decision on whether trans kids are better off being loved and supported or put through conversion torture. It is not acceptable.

I won’t dig into the details of the Cass report itself, but the references and evidence base are deeply biased and flawed. It is yet another total failure for trans kids in the UK.

There are still no trans experts involved in a senior role in the Cass review. There is no trans power at all.

The Cass process seem to think the exclusion of trans people is acceptable, because they have told themselves they are not dealing with trans people at all. They have told themselves they are dealing with healthcare for ‘children suffering from gender distress’. This phrasing has become standard.

Worryingly there are also trans-antagonistic people involved in the research for Cass.

This week, the world respected paediatrician with over a decade of practical hands on experience HELPING trans kids in Australia published a response to the Cass review in the British Medical Journal. That response is not open access to the public, but this is of incredible important to those who are directly affected (and now even threatened) by the Cass outputs, so I will put its text here:

Gender identity services for children and young people in England

Landmark review should interrogate existing international evidence and consensus

Ken C Pang, 1, 3 Jeremy Wiggins, 2 Michelle M Telfer1, 3

1 Royal Children’s Hospital; 2 Transcend Australia; 3 Murdoch Children’s Research Institute

The long awaited interim report of the Cass review was finally published in March this year.1 Commissioned in September 2020, the independent review led by paediatrician Hillary Cass examined NHS gender identity services for children and young people in England. These services are currently provided by a single specialist clinic known as the Gender Identity Development Service. After consulting people with gender diversity, health professionals, and support and advocacy groups, Cass expressed various concerns within her interim report, such as increasingly long waiting lists, the “unsustainable workload” being carried by the service, and the “considerable risk” this presented to children and young people.

Recognising that “one service is not going to be able to respond to the growing demand in a timely way,” Cass used her interim report to recommend creation of a “fundamentally different service model.” Under this model, the care of gender diverse children and young people becomes “everyone’s business” by expanding the number of providers to create a series of regional centres that have strong links to local services and a remit to provide training for clinicians at all levels.1 Although it remains to be seen how and when this key recommendation will be implemented, the proposal will be largely welcomed by gender diverse children and adolescents and their families in England. The shift away from centralised, tertiary, and quaternary centres is already occurring internationally, including in Australia,2 where local services are being enhanced to meet growing demand and provide more equitable and timely care.

Hormonal treatment
In what was likely a disappointment to many, the interim report did not provide definitive advice on the use of puberty blockers and feminising or masculinising hormones. Instead, Cass advised that recommendations will be developed as the review’s research programme progresses. In particular, the report expresses the need for more long term data to assuage safety concerns regarding these hormonal interventions. Although additional data in this area are undoubtedly needed, the decision to delay recommendations pending more information on potential unknown side effects is problematic for several reasons.

Firstly, it ignores more than two decades of clinical experience in this area as well as existing evidence showing the benefits of these hormonal interventions on the mental health and quality of life of gender diverse young people.3 -9 Secondly, it will take many years to obtain these long term data. Finally, Cass acknowledges that when there is no realistic prospect of filling evidence gaps in a timely way, professional consensus should be developed on the correct way to proceed.” Such consensus already exists outside the UK. The American Academy of Pediatrics, the Endocrine Society, and the World rofessional Association for Transgender Health have all endorsed the use of these hormonal treatments in gender diverse young people,10 -12 but curiously these consensus based clinical guidelines and position statements receive little or no mention in the interim report.

Indeed, there is no evidence, as yet, that the Cass review has consulted beyond the UK. This inward looking focus may be a reflection of how England’s gender identity service has come to chart its own path in this field. For example, its current use of puberty blockers diverges considerably from international best practice. In particular, NHS England mandates that any gender diverse person under the age of 18 years who wishes to access oestrogen or testosterone must first receive at least 12 months of puberty suppression.13 However, many young people in this situation will already be in late puberty or have finished their pubertal development, by which time the main potential benefits of puberty suppression have been lost.11 Moreover, using puberty blockers in such individuals is more likely to induce unwanted menopausal symptoms such as fatigue and disturbed mood.14 For these reasons, puberty suppression outside the UK is typically reserved for gender diverse young people who are in early or middle puberty, when there is a physiological reason for prescribing blockers.

Another possible reason exists for the Cass review appearing to have neglected international consensus around hormone prescribing. While the interim report often mentions the need to “build consensus,” Cass seems keen to find a way forward that ensures “conceptual agreement” and “shared understanding” across all interested parties, including those who view gender diversity as inherently pathological. Compromise can be productive in many situations, but the assumption that the middle ground serves the best interests of gender diverse children and young people is a fallacy. Where polarised opinions exist in medicine—as is true in this case—it can be harmful to give equal credence to all viewpoints, particularly the more extreme or outlying views on either side. Hopefully Cass will keep this in mind when preparing her final report.

The above is available on the BMJ here

(Back to me typing) The authors of the above include some of the most respected paediatricians with decade long expertise in working with trans kids in Australia. The Cass team should have been queuing up to learn from Australian experts. The fact they have totally ignored expertise from outside of the UK and its partner system in the Netherlands, strikes as amazing arrogance. The fact the Australian experts felt the need to write a submission to the BMJ to raise their concerns with the Cass report is again astonishing, and in another less transphobic country would set off alarm bells.

I don’t know where we go from here.

I do know the cards are now on the table. I have zero faith in the Cass process. It has already done more harm than good.

My number one hope for Cass was it would take significant strides in depathologising approaches to trans kids. It has done the exact opposite. 18 months in and they won’t even say the word trans.

I had hoped Cass would educate the public that being trans is not a problem or a pathology. It has done the opposite, and legitimised some incredibly problematising media pieces this week alone.

I had hoped it would move us from psychoanalysis to modern healthcare – instead people are using Cass to justify the need for exploratory therapy, conversion therapy by a different name.

I had hoped it would move trans kids’ healthcare away from a monopoly mental health trust to modern secondary or primary care. Instead, the focus appears to be on talk therapy to problematise trans-ness, without tackling the hostile climate that makes life so hard for trans kids, and perhaps with even less route to medical intervention where needed.

Cass has done nothing to highlight the biggest problem for many trans kids. The climate of societal transphobia. Just this week we have had headlines stating trans people can be humiliated and segregated as the UK tries to bring in a bathroom bill by the back door. Trans kids and adolescents have been in crisis again this week, many are really struggling with mental health. Not because there’s something inherently wrong with being trans, but because the UK is a hostile terrifying place to be trans as our rights are continually debated or taken away. Cass has done absolutely nothing to highlight the crisis in mental health caused by the terrible way our country treats trans people.

Cass has failed us on every level.

The whole process is cis-supremacism in full dominance.

Why do a bunch of cis people continue to debate and dictate whether or not trans kids should be put under conversion therapy.

Why do cis people continue to have all the power, and continue to use it to harm trans kids.

Trans liberation now. Trans kids deserve so much better than this.

 

 

5 thoughts on “The Failure of the Cass Review

  1. Curious Scottie … do you personally know of a young person who is wrestling with this? NOT from reports of others’ experiences. But someone you know and talk with regularly.

    Liked by 1 person

    1. Hello Nan. We do have a trans girl in Ron’s family. His sister’s son has a trans adult daughter. She has been transitioning for two years but struggling with it her entire life. Just not able to come out and get the help that would have made this all so much easier for her. She will be at the anniversary party that Ron and James are going to this month. I have never met her though. Hugs

      Liked by 1 person

  2. I’ve known 2 transgender people (in Kansas, even.) I can tell what I knew, or retell my story with watching Tom Snyder’s interview of Christine Jorgensen, https://www.youtube.com/watch?v=BIL8Z8OUn4E . I’d seen that a year before I met my first trans friend, and boy, was I glad I’d paid attention, so I had an open mind when I learned about them. I won’t clog the thread unless someone would like to read it, though. ☮
    You know, I believe it’s safe to say that each and every one of us has met or interacted with trans people and likely had no idea. And we’re all still here! 😀

    Liked by 1 person

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