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The Cass Report, billed as an independent review into NHS provision of transgender provision for adolescents was published today. I’ve read the summary and recommendations (the whole report runs to over 300 pages), and running throughout it are the scars of the so-called “culture war”—a social movement where transphobes who hold so-called “gender critical” beliefs have been campaigning to marginalise trans people and roll-back hard won protection in equality law.

The report itself acknowledges the toxicity of debate around transgender healthcare. I’m going to try and be fair to the report here and deal with it as neutrally as I can. Transphobia does not seem to be seeping out of its pores in the same way that a recent Department for Education consultation did, which explicitly framed the discussion through the lens of the “gender critical” philosophy.

It is undeniable the harm that the culture war fuelled by transphobia has caused, and this comes through in the report.

Anti-trans campaigners are litigious and well-funded (allegedly by far-right American fundamentalists), and using these legal weapons has been effective in securing their campaign goals in places with a management culture focussed on risk management and minimisation.

The result of this atmosphere of fear created by the anti-trans movement is one the review describes as a situation where other services in healthcare are scared to do anything when gender dysphoria is present. Instead, everyone is referred to the specialist gender services for unrelated or co-existing conditions, which they might not be able to deal with. This is well-known in the trans community as “trans broken arm syndrome“. This is true in both children and adults.

There is no doubt that in part this is due to the fear within the healthcare community of being dragged into the frontline of the culture wars, which has had the chilling effect of marginalising trans people so that only the gender clinics can help.

The Cass Review strongly advocates moving away from single specialist centres to a regional model of trans healthcare, closer to primary care. This is also something many trans people and advocates (including myself) believe would be a better system of healthcare delivery, but it describes the current situation as far from that. Other recommendations in the report are fair assessments of the current situation. In the void left by the failure of NHS healthcare, private providers like GenderGP have emerged, but their standards of care fall short of best practice (trans streamer F1nn5ter recently did a video about this). The Cass Report is right to be critical of this, and this is one of the biggest indicators of how current NHS provision fails.

Much is made in the report of the lack of quality research covering transgender health. Transgender health has often been seen as at best niche, and at worst, something to be actively destroyed. During Nazi rule, the world’s first and leading research centre was ransacked and the research burnt, as well as trans people being among the identities targeted in the holocaust. Other research has overly focussed on transgender women and bears an undercurrent of the fetishisation that we’re often targets of, yet remained influential in the field for decades.

One example of this is that there has never been a longitudinal study of the impact of progesterone alongside estrogen in feminising hormones, which are routinely denied due to evidence showing no effect on breast growth, but anecdotally has an effect on mental health, which has never been evaluated. The assumption of medical researchers that trans women are only interested in breast development, and not in the mental health benefits of the hormone which is available to cis women, is one example of research being rooted in trans misogyny.