What the Cass Review fails to tell us about growing up trans

Trans barrister Robin Moira White says the 388-page report was billed as a ‘new start’ for gender services in the UK – but its glaring holes, notably around controversial puberty blockers, will leave the NHS unable to deal with the real challenges faced by young trans people

‘It is not reassuring for trans people to see the Cass report welcomed by a slew of trans-hostile organisations’ (PA)

Trans people – particularly young trans people – have been repeatedly failed by the state for as long as I can remember.

Throughout the 2010s, London’s Tavistock Centre, the NHS’s only dedicated gender identity clinic for children and young people, became increasingly overwhelmed, with demand for its services far outstripping available resources. This was a position mirrored in adult trans services, too, where waiting lists can stretch to decades – or are closed entirely.

So, many of us hoped the review of NHS gender services for children and young people, conducted by Dr Hilary Cass, would prove a hopeful new start.

And there were, indeed, some hopeful signs. The move to regional centres in place of the single Tavistock provision, recommended in the interim Cass report published in February 2022, received a cautious welcome from trans people and those who support them. Unfortunately, Tavistock’s Gids (Gender Identity Development Service) clinic has now closed before the new centres have opened – leaving trans young people in an abyss of no provision at all. It is not clear how long that will continue.

The foundation of the final report is the suggestion that the evidence base is poor for the affirming treatment favoured by many trans people and the leading world body, the World Professional Association for Transgender Health: puberty blockers before 16, cross-sex hormones after 16, and confirmation surgery after 18.

An initial read of the 388-page report suggests that its criticism is either poorly thought through or just downright strange. Criticism is made of studies that don’t use a “double-blind” methodology. That approach might make sense when testing a new cancer drug in adults, where neither the patient nor the administering clinician know whether the patient has been given the drug under test or a placebo so that the true effect of the new drug can be measured.

Patients will have had this procedure explained to them. Such studies are highly difficult to run ethically in a child population, and the effect is that the evidence base for most child treatment is limited, even for common drugs, for which the results of adult studies are used. In some senses, they are impossible to run. It cannot be a correct approach to give some gender-distressed young people affirming drugs and others placebos, which would see the distress-inducing puberty continue, obviously for all involved.

Approaches such as considering other uses of relevant drugs have to be used. The most controversial – puberty blockers – have been used in cis children for many years to pause precocious puberty, and no one is suggesting that they should stop. Studies also point to the tiny number of detransitioners, or those who experience transition regret, which is between 1 to 3 per cent of patients – a figure far, far lower than common surgical procedures like hip or knee replacements in the elderly.

The downright strange exclusions in the report include scientific papers “not written in the English language” and those “published in the past two years”. How can those be sensible criteria to exclude material?

The report does not appear to suggest how the ethical problems in the approach it calls for can be solved. This tends to suggest that the report authors have not thought that through, or are, in fact, content to set an impossible-to-satisfy test for trans healthcare.

If the foundations of the report are unsound, it will totter and collapse, but not before it has done immense harm in the UK and across the world.

The self-selecting group of clinicians consulted in the study includes a third who believe there is no such thing as a trans child. This all sounds to me just like the doctors wheeled out in the 1980s and 1990s to say that PTSD wasn’t a “real” condition and could be safely ignored. We now understand the beneficial effects of the highly effective talking and other therapies deployed to deal with PTSD in different ways from other forms of mental illness.

It is not reassuring for trans people and those who support them to see the report welcomed by the slew of trans-hostile organisations, commentators and media and condemned by those who support trans people.

Ultimately, if the focus on trans medicine that Cass has brought results in adequate NHS resources being allocated to deal with the very real challenges that trans young people face, then some good may have come of it. But trans people are not holding their breath. If it becomes another excuse to marginalise, and delegitimise trans people, Cass will prove to be a backward step.

Robin Moira White is the first barrister to transition in practice at the discrimination bar