The UK trans community is concerned and dismayed that some Lib Dem parliamentarians seem to be excessively supporting the Cass review.
The Cass review might superficially appear to be reasonable and balanced, and few of us will closely read all 388 pages in order to form a different view than we are hearing from our broadly anti-trans media. But from a transgender perspective the signs of subtly biased language are clear from the start. Firstly, in the Chair’s Foreword:
“I have faced criticism for engaging with groups and individuals who take a social justice approach and advocate for gender affirmation, and have equally been criticised for involving groups and individuals who urge more caution.”
Why is caution ascribed only to the anti-trans side? In fact, caution is a major motivation for the pro-trans side, given the levels of anxiety and depression that can be experienced by those with gender dysphoria, reaching in some cases to suicidal thoughts.
The Foreword also introduces transition and detransition on an apparently equal footing. Yet in reality, all my experience points to detransition cases being a tiny fraction, with the vast majority of transitioners feeling happier as a result. Data backs this up with <1% of those regretting undergoing Gender Affirming Surgeries, making it among the least regretted surgeries carried out.
Another surprising note, from very early on in the review, is how it bemoans the “culture war” context and “toxicity” and exhorts for this to stop. Certainly we are in the midst of a culture war, and on more fronts than just transgender awareness, and that is sad and unfortunate, but why would this affect a scientific process such as the Cass review purports to describe? Surely, a scientific process would only accept input from experts presenting their views on the basis of evidence, and would simply discount anyone arguing a culture war point of view or exhibiting toxicity?
If you think about it, this really is a curious and critical question. Answering it reveals the heart of what was wrong with the Cass review process, and shows us why we should mistrust its conclusions.
WPATH (World Professional Association for Transgender Health) is the premier global body for transgender health, and their response to the Cass review highlights two overall flaws. Firstly, questioning the review’s selection and use of evidence:
“the Cass Review purports to make “evidence-based” recommendations based on six systematic reviews carried out by the University of York […] which do not contain any new research that would contradict the recommendations made in professional consensus guidelines of the American Academy of Pediatrics (AAP), the Endocrine Society, and WPATH”
and
“Care and treatment that is consensus and expert-based occurs in many areas of medicine, including pediatrics. The use of a randomized blinded control group, which would lead to the highest quality of evidence, is ethically not feasible. It is ethically problematic to induce people to participate in a research project as the only way to access a type of care that is evidence based, widely recognised as medically necessary, and often reported as lifesaving.”
These are in response to the Cass review discounting most of the evidence in support of gender affirming care because of it not following (in Cass’s view) a sufficiently rigorous methodology.
Secondly, questioning the personnel involved in the review:
“One senior psychiatrist at a gender identity clinic in England told a national newspaper […] that the failure to include those with personal or professional experience “had concerned many within the field.” They said: “The terms of reference stated that the Cass Review ‘deliberately does not contain subject matter, experts or people with lived experience of gender services’ and Dr. Cass herself was explicitly selected as a senior clinician ‘with no prior involvement… in this area.’ Essentially, ignorance of gender dysphoria medicine was framed as a virtue.”
In summary, it appears the Cass review was intentionally set up with a personnel biased against trans healthcare, then deliberately set its standards for evidence so as to exclude all the pro-trans studies and evidence that other transgender health bodies have found to be relevant. Naturally that bar then excluded most evidence on all sides, and hence the Cass review process was then largely reduced to being a toxic culture war, and not really a scientific process at all. Hence the bemoaning. Following that they have presented the “results” with a veneer of kindness and balance, and some of the recommendations may even be helpful, but we cannot trust them given the fatally undermined process.
I urge all Lib Dems, and especially our parliamentarians, not to accept the Cass review as the gospel that it is being pushed as. (And equally with the Levy review for adult trans care that seems likely to follow a similar path.) When your constituents approach you for support, when the government proposes policy, or when asked gotcha questions in the media, please respond to them all with liberalism and kindness, instead of reaching for a biased and flawed review that does not deserve your support.
* Nell Jerram is a Lib Dem activist in Cambridge
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14 Comments
This is an excellent piece that stands up well explaining why those who are demanding the uncritical acceptance of the Cass document are misguided or themselves biased. Thank you Nell.
Thank you for this much needed note of caution. I was dismayed to see Ed Davey broadly accept this.
I hope you don’t come under too much fire for posting it.
Good article. It’s very worrying how it’s applying such high standards – to an end that only seems to be designed to prevent trans people from accessing care. It wouldn’t be so bad if this was actually leading to improved standards but instead services are being shut down with no alternatives, abandoning people. That isnt a health service we should want. I admire the Lib Dems for being led by the evidence but we have to be critical of flawed reports like this – and let our belief in equality and freedom for all take precedence.
Moral of the Cass report.
If you want to argue that white is black – that a medicine which helps children is a danger to children – then you just get three biased critics together in a chain.
The first argues that white is hard to distinguish statistically from light grey (Tilly Langton, at the University of York).
The second worries that light grey is dark grey (Cass herself).
The third screams that dark grey is black and must be immediately banned (the health secretary, Victoria Atkins, and now Wes Streeting).
As propaganda goes, it’s a clever approach. Especially as it can be framed as protecting children from risk of harm. But then anti-gay, anti-Semitic and anti-Roma propaganda down the ages has used the same script : it’s always framed as about protecting children.
Especially noteworthy is how the evidence for cross-sex hormone therapy was treated by Cass. The systematic reviews (after discounting most of the studies, and reviewing only the ones graded “moderate”) showed unanimous findings that cross sex hormones in minors with gender dysphoria reduce their dysphoria and improve mental health.
Yet somehow this got translated into a message by Cass that the evidence was insufficient and “extreme caution” should be used in prescribing them. Somehow that got translated into the NHS stopping such treatments completely in the 16-17 age group and regulating them out of the private sector too.
Couldn’t agree more with this. The BMA has now panned the review, and as a party we need to be supporting evidence based policy, not policy based evidence creation.
Well quite. It’s a classic bit of Tory policy-based evidence making. But frankly, even if we accepted the Cass Review on its face (and we shouldn’t), the “implementation” since by politicians has been like a game of Telephone. Calling for more studies and evidence is one thing, removing those treatments entirely from the NHS “as a precaution” is another, and then again so is permanently banning them privately and publicly. The moral panic has well and truly gripped our political class, and they have taken the baton and run a mile further with it. We must not be complicit in all of this.
Labour, Conservative , and SNP. Have all endorsed the findings of the Cass review.
As night follows day the Libdems – when pushed, will belatedly endorse it’s findings.
No if’s no buts….
“… and Dr. Cass herself was explicitly selected as a senior clinician ‘with no prior involvement… in this area.’ Essentially, ignorance of gender dysphoria medicine was framed as a virtue.””
Absolutely!
Whilst there may be questions about the terms of reference Dr Cass had to work within, and with whom the review could seek evidence, it was absolutely correct to ensure that whoever led the review was not partial.
I think some are rather than accepting the limitations and thus asking “how does this move matters forward”, are simply throwing their toys out of the pram because it doesn’t give the result they are wanting.
An excellent rebuke Nell, thank you.
“Why is caution ascribed only to the anti-trans side?”
Well, if you assume that trans people are just deluded, then the idea that one should protect children (it’s always children, isn’t it) from delusionally taking puberty blockers because of their delusion that they are the other gender is an obvious conclusion. However, if one did not make that assumption, and , after careful consideration agreed with the child’s decision about their gender, then prescribing puberty blockers is the cautious move for those children. If they are right, and the evidence is that in most cases they are, the avoidance of major surgical interventions later in life and some irreversible skeletal changes is a huge benefit to them. And in the small number of cases where they are wrong, puberty can be restarted .
I think the Cass Report was a valuable piece of work. I’m glad the NHS is already implementing its recommendations. Lib Dems MPs could have voted against the extension of the wider ban on puberty blockers in relation to minors but chose not to do so. I think they made the right choice.
I think it’s not clear whether the party as a whole supports or opposes the Cass Report in the aftermath of the Labour leadership’s apparent acceptance of it. And I think your leadership wants to keep it that way.
It is clear the Party has an aspiration to future Self-ID legislation and a broadly ‘favourable’ attitude to the rights of trans and non-binary people, but no clear desire or consensus to go further than that. There’s a refusal from many people writing on here to accept that there is an obvious sulky stalemate in the party on wider issues related to trans rights, trans advocacy and how much the (minority) voice of gender-critical dissent to that position should be heard.
That’s partially obscured by loud noises trying to create the false impression a climate more totally favourable to the loudest voices in favour of a more activist trans-advocate position. To date, it seems, your current resting position as a party (which is probably unavoidable given the balance of both factions and ‘moderate’ apathy in the middle), is to make broad, trans-favourable noises internally (sometimes more specific, sometimes more vague), mutter it more quietly if you’re facing voters you think might be critical, wait to see if Labour changes the law for you, and hope the debate does not spark into any futher public acrimony that would attract negative attention from whatever quarter.
In response to Mark Johnston, note that both Victoria Atkins’ original “emergency” ban and Wes Streeting’s extension were passed by executive order, and neither have been voted on by MPs.
This by itself represented an abuse of executive privilege; there was no precedent for a health secretary suddenly banning an entire class of medicines that had been safely in use for decades, but only banning them for one particular purpose, one group of prescribers, one group of patients, and one particular time period of prescription.
We have to wonder what else a minister may suddenly decide is criminal (meriting a two year prison sentence for simple possession of the substance in question) and for whom.
Hopefully it will not be something that Mr Johnston requires for his own health or well being.
Perhaps worth noting Ed Davey said ‘politicians must adhere to the findings of the Cass Review’ in this 11 September pre-Conference interview. His specific words were: “I’m not convinced that it’s been based on the full evidence of the Cass Review, and I think we need to stick to the Cass Review. What I worry about this agenda is: if we say that ministers and MPs and politicians are going to tell the medical profession what they can and can’t do for any patient, that’s quite a worrying place. So, let’s follow the evidence.”
https://www.politicshome.com/thehouse/article/ed-davey-if-youre-ambitious-far-hopeful-its-doom-gloom