By Tomáš Tengely-Evans and Thomas Foster
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Cass Review opens door to more attacks on trans people

A deeply flawed report that boosts Tories, bigots and transphobes
Issue 2900
A picture of the Tavistock  clinic illustrating an article about the Cass Review

The Tories pledged to open eight regional clinics after the Tavistock Centre shut. Only one has opened (Picture: Guy Smallman)

Dr Hilary Cass’s review into trans children’s healthcare says it aims to “ensure children and young people who are questioning their gender identity” receive “care that meets their needs”. It ensures the opposite. 

The Cass Review on gender identity services for children, published on Wednesday, boosts Tories, bigots and transphobes and will make life harder for trans+ people. 

Dr Cass paints a picture of medics stampeding to hand out puberty blockers to children. One look at the waiting lists for trans healthcare shows a very different picture. 

Some 26,234 adults were waiting for a first appointment with an adult gender clinic as of August 2022—and 23,561 had been waiting for over 18 weeks. 

Approximately 7,600 children were on waiting lists of whom around 6,100 had been waiting more than 18 weeks. 

Sky, a trans woman in her early 20s, attacked the medical pathways the report shows. “The medical pathway in the report shows four steps—assessment, puberty blockers at around 12, oestrogen and testosterone at 16 plus and surgery at 18 plus,” she told Socialist Worker.  

“If you have any understanding of trans healthcare in Britain, you know this isn’t the case.”

Speaking about her experience, Sky said, “I got referred to the gender identity services when I was 17, which is six years ago. I didn’t get my first assessment until I was 22. Let’s be honest here. You don’t just go to an assessment and then get puberty blockers.

“I got on puberty blockers just because of a medical loophole. On the official route, I haven’t even met the endocrinologist.” The endocrinologist is the doctor that can provide hormone treatment.

“I’ve been on the waitlist for many years. I’ve had three assessment appointments,” she said.  “To believe that you go for an immediate assessment, immediately get puberty blockers and then if you are old enough testosterone or oestrogen and then surgery is absurd.

“I’ve been bluntly told I won’t get surgery for six or seven years. The picture that they are painting in this report is farcical.”

Sky described the experience of many young trans+ people. “The first thing that you do when you are trans isn’t going to your doctor,” she explained. The first thing is you look towards the closest people and confide with them. The next thing you do is start a social transition.

“Then the next thing most likely is changing your name. And only then do you look at any medical intervention. It is the last thing you do.”

She added, “They are medicalising being trans. They are also scaremongering about ‘irreversible care’.”

“Puberty blockers are reversible and hormone therapy in many circumstances is reversible. To medicalise being trans is playing into right wing culture wars and is a tool to put young trans people in danger and force people back into the closet.”

The crux of the report’s case rests on studies into puberty blockers being “poor quality”. Such medication, which is reversible, puts on hold the largely irreversible and sometimes distressing physical changes of puberty

Cass says, “When the review started, the evidence base, particularly in relation to the use of puberty blockers and masculinising/feminising hormones, had already been shown to be weak. 

“There was, and remains, a lot of misinformation easily accessible online, with opposing sides of the debate pointing to research to justify a position, regardless of the quality of the studies. 

“To understand the best way to support children and young people, the review’s ambition was therefore not only to understand the existing evidence, but also to improve the evidence base.” 

How does it “improve” the evidence base? It doesn’t—instead, it holds trans healthcare to an “impossible standard”. 

Cass privileges studies that include Randomised Control Trials (RCTs) as the “gold standard”. It’s a clinical study where there are two groups—one taking a new treatment and a second “control group” takes an existing treatment or has no treatment at all. 

A separate document linked to the review dismisses a vast number of studies as, “Assessed as at high risk of bias (lack of blinding and no control group).”

 

Blinding means either the researchers don’t know which group patients are in, or patients don’t know if they’re on the new treatment, the original treatment or a placebo. 

But Alejandra Caraballo, a US civil rights attorney who works at Harvard’s cyberlaw clinic, said everyone will soon know if they are on a placebo or not.

“Patients are going to notice hormones when they develop breasts and facial hair,” she said. 

“When you hear the anti-trans side screaming, ‘The evidence is of poor quality’, this is what they’re referring to.” 

She added that they “hold trans care to an impossible standard and use it to undermine access”. 

Trans academic Dr Natacha Kennedy, co-chair of the Feminist Gender Equality Network, agrees. “Anti-trans activists have been disingenuously calling for RCTs in transgender healthcare for a long time despite it being quite obvious that RCTs for transgender health are both unethical and impossible,” she writes. 

The Cass Review’s proposals for a more “holistic” approach to care delivered across England sound harmless—or even positive.

Addressing trans children, she writes, “I know you need more than medical intervention, but services are really stretched. 

“And you are not getting the wider support you need in managing any mental health problems, arranging fertility preservation, getting help with any challenges relating to neurodiversity, or even getting counselling to work through questions and issues you may have. 

“We need to look at all the elements that are needed in a package of care that will help you thrive and fulfil your broader life goals.” 

She continues, “The first step for the NHS is to expand capacity, offer wider interventions, upskill the broader workforce, take an individualised, personal approach to care, and put in place the mechanisms to collect the data needed for quality improvement and research.” 

You only have to look at what happened after Cass’s interim report was published to know the report will have the opposite outcome. NHS bosses shut the gender identity development service at the Tavistock centre in east London in 2023. 

The Tories pledged to open eight regional clinics delivering “a different model of care”. Only one has opened—and waiting lists remain astronomical. So, instead of a better model of holistic care, the Tories will use the Cass report to attack trans healthcare for all. 

The Tories will use Cass to go on the offensive—and Labour is going along with their transphobia. Wes Streeting, Labour’s shadow health secretary, pledged the party’s “support for the Cass Review’s evidence-led recommendations”.

We need a mass fightback for self-identification now, a trans-inclusive ban on conversion therapy and health care—and trans+ liberation. 

A group of young trans people have organised a “Trans Strike Back” protest against the NHS England ban on hormone blockers. Saturday 20 April, 11.30am, Parliament Square, London


Don’t accept Cass’s biological determinism 

The Cass review is underpinned by “biological determinism”, ideas that claim gender is rooted in biology. 

It says, “A common assumption is that toy choice and other gender role behaviours are solely a result of social influences; for example, that boys will only be given trucks and girls will only be given dolls to play with. 

“Although this is partially true, there is evidence for prenatal and postnatal hormonal influence on these behaviours.” 

But human biology isn’t fixed and unchanging—whatever the transphobes would have us believe. 

Cass goes on at great length about height differences between men and women—the relevance isn’t obvious. And height is, in fact, an example of something “biological” that has changed due to social factors, such as diets or poverty, over time.  

Gender informs our closest relationships with each other. Sometimes even before a child is born, they are gendered as male or female, with the intention that it lasts for the rest of their lives.

But, while being deeply personal, gender is shaped by social forces. The assumptions we make about a person’s gender are informed by the dominant ideas about gender as being rooted in biology, binary and unchanging. 

And they’re picked up, as the scientist and author Cordelia Fine argues, through ­“parents, peers, teachers, clothing, language, media, role models, ­organisations, schools, institutions, social inequalities and of course, toys.”

Does this mean biology is unimportant, or has nothing to do with how we’re gendered? Human reproduction has relied on biological differences—what we would conceive of as two sexes, male and female. 

Some humans are born with wombs, some are born without wombs. And, of course, biological differences between what we define as male and female sex organs are real. 

But it’s the socially-made gender differences that matter and mean that biological differences can take on an importance. 

A wealth of anthropological evidence shows that different biological reproductive capacities didn’t always mean differences in social status or power between genders in earlier societies. 

We’re proud to say, “Trans women are women,” “trans men are men,” and non-binary people exist and should be respected.

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