UK Cast Review flops badly for trans kids

UK Cast Review flops badly for trans kids

By Cal Horton & Ruth Pierce

Over the past decade, a growing moral panic over the existence of transgender people has engulfed both the UK and the US. Fears, particularly about the experiences of children, have been fuelled by years of provocative media coverage. And political posturing. Common misinformation includes unfounded claims that transgender children are victims of a “psychiatric epidemic” or a “social contagion,” that they are being “transitioned” against their will, or that they are being rushed through medical procedures.

Amid growing campaigns to roll back legal protections and healthcare provision for transgender people in 2020, the UK’s National Health Service (NHS) launched the Cass Review of publicly funded gender services for children in England. Led by retired paediatrician Hilary Cass, the review examined existing research on healthcare interventions for transgender people under the age of 18, consulted with stakeholders, and made recommendations for NHS England’s services.

The Cass Review’s final report was released in April. It expressed concern about the high number of young transgender people visiting doctors’ offices for treatment and argued that the “evidence is significantly weak” showing the benefits of gender-affirming medical interventions. For example, it recommended that puberty suppressants (medications given to delay puberty) be administered only within the context of clinical trials. For young children who have not yet reached puberty, it warned about social transitions – non-medical decisions that children may make on their own, such as changing their name, wearing different clothes, or choosing to be called by different pronouns.

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“The Cass report has been presented by the British media, politicians and prominent doctors as a triumph of objective research, but its most controversial recommendations are based on prejudice rather than evidence. Far from helping young people, the report does great harm to children and their families, democratic debate and the broader principles of the scientific endeavour. A critical examination of the report’s actual context and findings is urgently needed.”

The anti-transgender credentials of the Cath Review were clear from its inception in 2020. It explicitly excluded transgender people from any key role in the research, analysis and oversight of the project, and sidelined most experts with transgender medical experience. The project centred and aligned with anti-transgender voices, including experts who deny the very existence of transgender children. Former UK Minister for Women and Equalities Kemi Badenoch, who had a history of hostility towards transgender people despite her role in promoting equality within government, boasted that the Cath Review was only possible because of her active involvement.

The methodology underlying the Cass Review has been extensively criticized by medical professionals and academics across disciplines. Criticisms have focused particularly on the influence of bias on the Cass approach, double standards in interpreting data, substandard scientific rigor, methodological flaws, and failure to adequately substantiate claims. For example, the Cass Review warns against the widespread reporting of important benefits of social transition in the existing literature, while reporting no credible evidence of harms. The review also dismisses important documented benefits of adolescent medical transition as lacking evidence, and highlights risks based on grossly poor quality evidence. For example, the warning about impaired brain maturation cites one very short, speculative paper based on one experimental study in female mice, while extensive qualitative data and clinical consensus are almost completely ignored. These issues help explain why the CASS recommendations differ from previous academic reviews and expert guidance from leading medical organizations such as the World Professional Association for Transgender Health (WPATH) and the American Academy of Pediatrics.

WPATH experts themselves highlight the Cass report’s “selective and inconsistent use of evidence” and recommendations that “often are not derived from data presented in systematic reviews.” Leading transgender health experts in the United States and Australia stress that “the review obscures important findings, misrepresents its own data, and is riddled with misuse of the scientific method.” For example, the Cass report warns that the “sharp change in referrals” to child and adolescent gender clinics in England in the 2010s was “much faster than expected.” However, this increase is not steep, and the up to 5,000 referrals in 2021 that the report points out represent only a tiny proportion of the 44,000 transgender youth in the UK estimated from 2021 census data.

The Cass report received enthusiastic support from all sectors of the British media and was immediately endorsed by the UK’s two largest parties, the Conservatives and the Labour Party. The report was hailed as evidence that trans rights had “gone too far”, legitimising years of hateful propaganda. Many politicians and commentators made no mention of the risks and harms contained in the Cass report’s recommendations – harms that are already being acutely felt by transgender children and young people in the UK and abroad. The Endocrine Society warned that “misinformation about gender affirming care is being politicised”.

Young transgender people across the UK face numerous abuses and humiliations, promoted and legitimised by the Cass Review. Families, schools and social services are warned against supporting transgender children with social transition, advice that will keep them in a situation of long-term rejection and shame. Newly established gender services in England are not authorised to provide affirmative care, instead focusing on invasive and exhaustive assessments. Being transgender is seen as an innate problem, rather than a valid human identity.

In the UK there is currently no pathway to begin NHS healthcare transition for people under 18. Puberty suppressants are only hypothetically available through proposed clinical trials that have never been planned or started. Whether or not this unethical trial actually takes place is not the issue; this is merely a way for the NHS and the UK Government to deflect accusations that they are banning adolescent healthcare.

In May, the outgoing Conservative government used rarely used emergency powers to criminalise the possession of puberty suppressants privately obtained outside the NHS. After Labour’s subsequent general election victory, the new Health Secretary, Wes Streeting, voiced his support for the ban, citing the Cath Review. The criminalisation only applies to transgender young people; cisgender children and young people can legally access puberty suppressants for the same purpose of stopping puberty, and the same drugs continue to be prescribed for a range of other conditions and uses.

It is estimated that over 1,000 transgender young people in the UK are currently aware that treatment is illegal. Families risk up to two years in prison for supporting their children’s continued access to private medicines. These young people face state-mandated medical de-transitioning, forcing them to go through the adolescence they have so desperately avoided. The alternative is to flee the country or take greater risks – continuing blockers under threat of prosecution, or taking alternative drugs with more frequent and severe side effects. Families tell us their transgender children are withdrawing from regular hormone monitoring tests and wider health services out of fear.

Transgender young people have been under severe stress for many years in the UK and around the world, facing increasing hostility, persecution and violence. The transgender community and supporting families are now desperately trying to highlight the current threats to the safety of transgender young people. In July, a group of transgender teenagers staged a dramatic four-day sit-in at NHS England headquarters, protesting with the slogan “transgender kids deserve to be treated better”. The unprecedented action was largely ignored by the UK media, once again exposing the systemic power imbalances that leave transgender young people in a vulnerable position in the UK.

Transgender children now need vocal allies not only from academic, medical and political communities, but from the general public at large. We must speak out about the serious failures of the Cass Review, acknowledge the violent harm it has already caused, and actively work to ensure that all children have access to non-stigma health care.

This is an opinion and analysis article and the views of the author are not necessarily those of Scientific American.