Two cheers for the Cass Review, but...

In our latest guest essay by a Battle of Ideas festival speaker, Dr Jenny Cunningham, a retired paediatrician, explains why the Cass Review has been invaluable – but not without some weaknesses.

Sep 24, 2024

The Battle of Ideas festival 2024 takes place on Saturday 19 & Sunday 20 October, featuring 100 debates, hundreds of speakers and thousands of attendees. The festival is a fantastic opportunity to be part of thought-provoking discussions on a huge range of issues. You can see the full programme here and buy tickets here.

Even better, sign up as paid subscriber to our growing Substack community and get a big discount on Battle tickets. Paid subscribers can also join our special subscriber-only briefing on Tuesday 24 September where the Battle team will be on hand to give the lowdown and behind-the-scenes insights into this year’s festival.

Retired paediatrician and education campaigner Dr Jenny Cunningham is taking part in the session Neurodiversity to gender dysphoria: a problem of over-diagnosis? There is also a separate debate at the festival titled From WPATH to the Cass Review: the crisis in medical ethics.

Here, Jenny takes stock of the Cass Review, arguing that it was a major breakthrough in terms of the public discourse around gender identity – but expresses concerns about some assumptions the Review makes.

This essay was first published by the Scottish Union for Education, which aims to involve more people from communities - including parents, grandparents and educators - to improve Scottish educational establishments as places of learning rather than sites of activism. Follow their Substack here.

Why has Dr Hilary Cass’s independent review of gender identity services for children and young people had such an impact in the UK and internationally?

It is the most comprehensive scientific evaluation to date of evidence regarding the psychological and medical treatment of children and adolescents with gender incongruence/dysphoria [1]. It took four years and was based on seven peer-reviewed systematic literature reviews by researchers at the University of York, together with qualitative research to capture the experiences of children and young people referred to gender identity services, as well as the experiences of their families. The systematic reviews – which represent the highest level of evidence – covered every aspect of gender identity services: care pathways, particularly those following the ‘gender affirmative model’; the characteristics of children and young people referred to gender identity services; use of puberty-suppressing hormones; use of masculinising and feminising hormones; psychotherapeutic interventions; the impact of social transition; and the quality of international and regional guidelines for gender care.

The Review found ‘remarkably weak evidence’ (Final Report, p. 13) for the use of puberty blockers and cross-sex hormones, and was highly critical of the clinical assessment and management of cases and of the gender-affirmative model of care in gender identity services in the UK and internationally.

WHAT HAS THE REVIEW ACHIEVED?

It has discredited affirmative gender care – the unquestioning affirmation of a child/young person’s desire to change gender, the facilitation of their medical transitioning, and the concomitant failure to fully assess other conditions complicating their gender-questioning or distress.
It has discredited the influential international guidelines that have justified the provision of affirmative gender care, especially the World Professional Association for Transgender Health (WPATH) and Endocrine Society guidelines – demonstrating their lack of developmental rigour, the poor quality of evidence, and the use of each other’s recommendations to create apparent consensus.
As a result of the Review’s recommendations, the gender identity development service for children and young people in England (the Tavistock GIDS in London) was closed and NHS England is establishing regional paediatric gender services; it banned the prescription of puberty blockers for under-18s. NHS Scotland has ‘paused’ the prescription of both puberty blockers and cross-sex hormones for those under 18 by the Scottish gender identity service for young people (at the Sandyford Clinic in Glasgow). The UK government has extended the ban on puberty blockers to cover private gender services in the UK and abroad.

WHAT ARE THE STRENGTHS AND SHORTCOMINGS OF THE REVIEW?

These fall into two areas: first, the characteristics of those referred to gender identity services; and second, the deficits in the assessment, diagnosis and treatment of gender-questioning young people.

What kind of people are referred to gender-identity services?

The Review’s first strength is its comprehensive consolidation of our knowledge about the very new cohort, of predominantly adolescents, being referred to gender identity services. It examines in detail the exponential increase in referrals to the Tavistock GIDS from 2014–2015 (a trend mirrored in Scotland and internationally) and what has changed when compared with the previously small numbers (of mainly young boys) presenting in the 1990s and early 2000s.

There has also been a change in the gender ratio, with over 70 per cent being teenage girls. The majority of these teenagers did not experience gender unease or confusion in childhood, but instead showed what has been referred to as ‘rapid onset gender dysphoria’ in adolescence. This cohort of teenagers is remarkable for what Cass describes as its ‘complexity’ – with a high incidence of associated or comorbid problems, including mental health conditions (such as body dysmorphic disorder or anorexia nervosa), autistic spectrum disorders, and adverse social experiences (many are in the care system or have a history of sexual or physical abuse and family breakdown). A large proportion are lesbians, gays or bisexual.

It is where the Review posits possible reasons for the exponential rise and the complexity of this new cohort that it appears most limited. This is summarised in one paragraph (p. 27):

Research suggests gender expression is likely determined by a variable mix of factors such as biological predisposition, early childhood experiences, sexuality and expectations of puberty. For some, mental-health difficulties are hard to disentangle. The impact of a variety of contemporary societal influences and stresses (including online experience) remains unclear. Peer influence is also very powerful during adolescence as are different generational perspectives.

By ‘generational perspectives’, Cass means that Generation Z (today’s 13- to 27-year-olds) are more accepting of the ‘mutability of gender’ than older age groups (p. 120). Biological predisposition is the most speculative: despite the lack of evidence for a biological cause of gender incongruence, ‘it may be that some people have a biological predisposition’ (p. 122).

Although the Review is written within a medical framework, nevertheless, what is most striking is that it leaves out of its account the preceding growth of transgender ideology, together with the spread of transgender activism in academia, education, institutions such as the NHS, and virtually all the psychotherapeutic organisations.

The start of the exponential rise in referrals to gender services in the UK coincided with the 2014 BBC documentary I Am Leo – 12-year-old Leo’s story about ‘growing up in the wrong body’: how Lily socially transitioned into Leo at the age of five and subsequently began medically transitioning, with puberty blockers supplied by Tavistock GIDS, together with counselling about what it means to be transgender [2].

In 2015, Stonewall, the organisation that had campaigned for equal rights for gays, lesbians and bisexuals, added the ‘T’ to LGB. One plausible explanation is that once marriage became legal for same-sex couples in the UK, in July 2013, Stonewall needed a new (lucrative) focus and transformed itself into a transgender lobby group, utilising its extensive existing connections in political, state and institutional structures.

Subsequently, large numbers of transgender organisations were spawned and transgender activists quickly gained influence in schools, universities and the NHS. At the same time, health professionals at Tavistock GIDS and the Sandyford Clinic adopted a gender-affirming model of care, under the WPATH 7 guidelines. The prescription of puberty blockers was liberalised, with children/young people almost invariably moving on to cross-sex hormones. Teaching staff were permitted or encouraged to allow the social transitioning of ‘trans kids’ in schools.

It is only in the context of transgender activism that sense can be made of Cass’s observation that ‘peer influence is […] very powerful during adolescence’.

The Review noted that it ‘heard accounts of female students forming intense friendships with other gender-questioning or transgender students at school, and then identifying as trans themselves’ (p. 122). It also observed that ‘the term social contagion’ is a contested explanation, ‘causing particular distress to some in the trans community’ (p. 117). Of course it upsets transgender activists, who argue that ‘trans people’ have an innate gender identity that is in conflict with the gender they are ‘assigned’ at birth (as if the registration of a baby’s sex is some arbitrary allocation). However, social contagion does have explanatory power in terms of the sudden surge of adolescent girls claiming to be ‘trans’.

The failings of assessment and treatment

The second strength of the Cass Review is its focus on the inadequacies of the assessment, diagnosis and clinical management of young people by gender identity services. In the Interim Cass Report, published in February 2022, Cass stressed that once gender-related distress was identified, it tended to ‘overshadow’ other explanations and limit the assessment of coexisting conditions. In the Final Report, it is argued that in terms of the international guidelines for gender care, ‘the most striking problem is the lack of any consensus on the purpose of the assessment process’ (p. 28) – the inability to establish whether or not treatment is necessary.

Although a diagnosis of gender dysphoria has been regarded as necessary for starting medical treatment, ‘it is not reliably predictive of whether that young person will have longstanding gender incongruence in the future, or whether medical intervention will be the best option for them’ (p. 29). In other words, a formal diagnosis is not predictive of the persistence of gender incongruence or of desistence – the reversion to one’s heterosexual or same-sex attracted status.

Studies suggest that up to 80 per cent of young people will desist if not medically transitioned, having come to terms with their bodies and sexuality. Cass has said that the difficulty is knowing into which group an individual will fit; hence the need for extreme caution in instigating medical transitioning. This is particularly so given the as-yet-unknown but increasing numbers of young adults detransitioning. The time to detransition is estimated at between five and 10 years (p. 188).

A key weakness of the Cass Review is its acceptance that the psychiatric diagnosis of gender incongruence represents a genuine condition which has some underlying cause that can be treated by medical interventions – at least in some cases.

In medical diagnosis, people present with symptoms that are often very general and subjective. Doctors have to identify signs that can be observed and tested for (eg, signs of infection or other abnormalities found through scans or tests of blood pressure, blood or tissue samples, etc). Results are then fitted into disease patterns established by medical research.

However, as Lucy Johnstone points out, with very few exceptions, psychiatric conditions present with symptoms, but there are no proven biological causes or measurable, verifiable signs [3, pp. 26–27]. Diagnoses are agreed by committees of experts on the basis of behavioural features and symptoms. There are two classification systems: the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, now in its fifth edition (DSM-5) (2013, revised 2022) and the World Health Organisation International Classification of Diseases, eleventh edition (2022).

The DSM-5 diagnosis of gender dysphoria is a good example of these points. DSM-5 defines gender dysphoria in adolescents (and adults) as ‘a marked incongruence between one’s experienced/expressed gender and one’s assigned gender, lasting at least six months, as manifested by at least two of the following’ – for example:

a strong desire to be rid of one’s primary and/or secondary sex characteristics
a strong desire for the sex characteristics of the other gender
a strong desire to be of the other gender
a strong desire to be treated as the other gender
a strong conviction that one has the typical feelings and reactions of the other gender

To meet the criteria for the diagnosis ‘the condition must be associated with clinically significant distress’ [4].

This raises more than a few questions. What does ‘a strong desire’ mean when it is immeasurable and entirely subjective? What does it mean ‘to be of the other gender’? How can one have ‘the feelings and reactions’ of the opposite sex? What is ‘significant distress’?

Reading the DSM-5 on gender dysphoria can leave one in no doubt that the American Psychiatric Association is in the grip of transgender ideology – from the adoption of its terminology to its recommendations for treatment: ‘Support may also include affirmation in various domains’, such as social affirmation or legal affirmation. ‘Medical affirmation may include pubertal suppression for adolescents […] and gender-affirming hormones like estrogen and testosterone for older adolescents and adults […] Some adults (and less often adolescents) may undergo various aspects of surgical affirmation.’

Gender dysphoria is the only clinical symptom in DSM-5 whose treatment involves sex hormone manipulation and surgical intervention. It is the view of Paul McHugh, Distinguished Service Professor of Psychiatry at Johns Hopkins University Medical School, that gender dysphoria, a term for ‘feeling oneself to be of the opposite sex’, belongs to the family of ‘similarly disordered assumptions about the body, such as anorexia nervosa and body dysmorphic disorder. Its treatment should not be directed at the body as with surgery and hormones any more than one treats obesity-fearing anorexic patients with liposuction.’ The treatment needs to attempt to correct the false/delusional belief and ‘to resolve the psychosocial conflicts provoking it.’ [5]

There is no contradiction between McHugh’s characterisation of gender dysphoria as part of a group of delusory mind–body disorders and the conception of it as a social contagion among teenaged girls. The latter is well known in relation to anorexia nervosa, but what is specific to the contemporary phenomenon is that teenagers have been so thoroughly inducted into transgender ideology in schools and online and imbued with the fallacy of sex being on a spectrum and mutable. Gender dysphoria/incongruence is part of a cultural narrative that confers attention and endorsement.

However, it is wrong to argue that gender dysphoria does not exist – that it is simply synonymous with the comorbid conditions affecting many of the young people in the new cohort of referrals to gender identity services. It very definitely exists in the sense that it is given a material transgender form – a masculinised female or a feminised male – through medical and surgical gender treatment, with its serious, life-changing sequelae. It should not be underestimated how important it is for transgender ideologues to have their mendacious belief in innate gender identity embodied in transgender individuals, and young people recruited to their ranks and transitioned. They legitimatise and validate transgender identity, putting it on a par with sexuality.

That is why transgender activists in transgender organisations and among health professionals are so opposed to the Cass Review and its discrediting of affirmative gender care. It is also why the Cass Review needed to have been more circumspect about suggesting that medical transition may be appropriate for some young people or that it would be ethical to conduct research to find evidence for or against the use of puberty blockers in children or adolescents.

Notwithstanding such reservations about its limitations, the Cass Review has been an invaluable challenge to the orthodoxy of affirmative gender care, and it has created the space for reasoned debate around these issues in the UK and internationally.

Dr Jenny Cunningham was a community paediatrician in Glasgow for over 30 years, with expertise in paediatric neurodisability and autism, until retiring in 2016. Jenny is on the board of the Scottish Union for Education (SUE), which campaigns against indoctrination in Scottish schools, and is the author of SUE’s pamphlet, Transgender ideology in Scottish schools: What’s wrong with government guidance?