By Thomas Foster
Downloading PDF. Please wait... Issue 2901

Cass Review will ‘perpetuate systemic injustices’ say health workers

A child educational psychology worker, a child and young person’s mental health worker and a health worker give their verdict on the Cass report
Issue 2901
A picture of the Tavistock illustrating an article about the Cass Review

After Cass’s interim report was published, NHS bosses shut the gender identity development service at the Tavistock centre (Picture: Guy Smallman)

Dr Hilary Cass’s review into trans children’s healthcare is deeply flawed and full of misunderstandings.

The report, published on Wednesday, concludes that the evidence for using puberty blockers is “weak”.

But Christabelle, who does child educational psychology work for a London council, told Socialist Worker, “The evidence base of the report and analysis of the evidence is awful.” She explained that Cass’s “main rationale for not taking into account research that pointed towards using puberty blockers as positive was because it didn’t use a ‘double blind’”.

A “double blind” study is where one group of patients receive the drug and another group a placebo, with the participants unaware of which one they’ve received.

This meant the literature review, which the report’s conclusions are based on, “excluded hundreds of studies, particularly, international studies”. These show that “puberty blockers and hormone treatments lead to positive outcomes for mental health and social outcomes for young trans people”.

Christabelle explained that “double blinds don’t happen in every piece of medical research”. “You can’t have a double blind study when the medicine relies on stopping physical changes,” she said.

“You don’t do double blinds for a vaccine trial. Why would you do a double blind for something as important as a gender identity, when putting gender dysphoria at bay when it has such a big impact on mental health.

“It would be unethical. You would be telling people that you are providing a medicine that will stop the process of puberty and support their transition when it’s just a placebo.”

The Cass Review’s proposals for a more “holistic” approach to care delivered across England sound harmless—or even positive. But, on top of its flawed research, the Tories will use it to undermine trans healthcare.

Monica, a worker in child and adolescent mental health services, said, “I think the report calling for a holistic service for people with gender dysphoria is a good thing.”

But she argued, “The report has a poor characterisation of an affirmation model of gender identity services—it’s overly simplistic. It characterises gender affirmation services as agreeing with the young person and nothing else”.

“But when you look at what clinicians say, that isn’t how affirmation works in practice. In practice, clinicians accept what young people are saying to us but are also open to these things being fluid. Gender affirmation services still accept that children are developing.

“Clinicians in gender affirmation services talk about young people having a subjective gender experience but also remain open to changes over time.” She said the report’s right about the need for “more research into gender identity child services, but that shouldn’t be used to stop access to medical support”.

The report acknowledges that children’s mental health and paediatric services “are stretched across Britain”. But it implies trans children miss out because they’re on waiting lists for gender services. “Gender-questioning children and young people appear to be disproportionately disadvantaged because they are frequently bypassed by local services once on a waiting list for gender services,” it said

“Being trans can have nothing to do with mental health difficulties,” Monica said. “The difficulties can come from bullying from students or teachers at school. But gender dysphoria can cause mental distress. For example, menstruation for young trans people can be a monthly reminder that their body is betraying them.

“We of course need a way to help people with any mental health difficulties, but that shouldn’t block them from getting support with their gender issues.

“You have other young trans people, who in a different world where they’re  accepted for who they are, wouldn’t have any issues with their mental health.

“It’s much more about how society impacts on people that leads to mental health problems, and a convergence between their body and their gender identity.”

Christabelle added, “I’m also worried about the challenge of supporting the mental health of trans young people. If young trans people in schools don’t have access to gender affirming health care, how are we going to support them? The report falls short on that.”

What we need instead is healthcare “centred on children’s rights and listening to children and people making decisions on their own healthcare, within reason”.

Maggie, a healthcare worker from south London, told Socialist Worker that the report has “fundamental problems”. “The Cass report implies that ‘trans ideology’ took over the Gender Identity Clinics (GIDS) and that puberty blockers are part of this ‘trans ideology’,” she told Socialist Worker. “I completely disagree with that.

“The GIDS service was clear that puberty blockers are about giving people time to think, about putting puberty on hold.”

Puberty blockers help “young people who reach puberty and find it unbearable—that was driving the use of the blockers,” Maggie said.

“The closing of the Tavistock clinic has meant we’ve lost all expertise that was at the GIDS clinic. They had maybe 30 to 35 staff and something like 5,000 young people on the waiting list. Whatever dysfunction about the GIDS service, they were completely overwhelmed.”

After Cass’s interim report was published, 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”—but only one has opened.

Maggie said the government “needs to be putting more money into both gender and Camhs services” but will do the opposite.

Maggie said, “The government is going to move on to a report on adult gender services. But in the research that the University of York did for Cass’s report, seven out of eight adult gender services refused to comply with the research.”

She said services “aren’t putting up blocks or barriers—they didn’t trust the process given how young trans people are being attacked”.

We need a fightback against the attacks on trans people—and for self-identification now, a trans-inclusive ban on conversion therapy and health care.

As Christabelle said, “The report is going to perpetuate systemic and sustained injustices and add to the cumulative stress that trans young people go through.

“Healthcare and educational workers need to coordinate a response against this anti-trans rhetoric, including pressuring trade unions. We need to coordinate how we can provide meaningful support that affirms trans identity.”

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

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