Roundup on the Controversial Cass Review, May 2024

You may have heard about the Cass Review.

In 2020, the NHS (National Health Service) in the UK ordered a review of the state of gender affirming care for youth in the UK. Dr. Hilary Cass, a pediatrician, was given this task. The final report was released on April 9, 2024, and immediately caused controversy and has been used to justify additional limitations on care for UK youth, and used as a support to justify discriminatory care and care bans for US youth.

Important To Note:

• The Cass report does not apply to US care, but is being used as evidence to restrict care in the United States.
• Prior to the Cass report, it was already difficult for adolescents to access care in the UK. It is now nearly impossible.

In the past 6 or so weeks since the Cass Review was released, there have been a swirl of responses to the review. We’re not even going to try to do a systematic review of the review. Other people with time, expertise, and budgets have already done so. We can point you towards what has been published in response and the growing consensus of opinions: the Cass Review is deeply flawed and comes from a place of transphobic bias.

Some Background Readings:

Erin Reed’s April 10th article, “Cass Met With DeSantis Pick Over Trans Ban: Her Review Now Targets England Trans Care” is good, concise starting point for understanding the controversies.

If you’ve an urge to read a journal article, Cal Horton published a review of the intermediate Cass Review publications between January 2020 and May 2023:

• The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children.
  Horton, C. (2024). The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children. International Journal of Transgender Health, 1–25. https://doi.org/10.1080/26895269.2024.2328249 (published online 3/14/2024)

More Accessible Readings:

Cal Horton also published an informal discussion of the Cass Review Recommendations in April, 2024 on his blog. This blog article is a less scholarly discussion of the harms of the Cass Review recommendations:

• Ten Dangerous Cass Review Recommendations (Cal Horton, Growing Up Transgender, 4/16/24)

Gemma Stone of Trans Writes published a point-by-point plain (and pissed off!) language rebuttal of the Cass Review recommendations on 4/15/24: The 32 things The Cass Review recommends and why they are concerning. It is more specific to accessing care in the UK, but highlights some of the whys that that transphobes use to restrict or deny care:

“Given that we know The Cass Review has been majorly influenced by anti-trans activists with ties to conversion therapy efforts, it’s probably worth looking at some of the recommendations and how they relate back to what transphobes are doing to organise against trans liberation.”

Tracking The Conversation: Articles in Chronological Order

Erin Reed (Erin in the Morning) and Evan Urquhart (Assigned Media) have been keeping up with personal responses and breaking news about controversial Cass Report methodology, influences, and reactions. Dr. Ruth Pearce also tracks continuing developments from a UK perspective (Glasgow, Scotland.)

Update July 2024 – an report out of Yale on the Cass Review.

• Cass Met With DeSantis Pick Over Trans Ban: Her Review Now Targets England Trans Care (Erin Reed, Erin in the Morning, 4/10/24)
• What’s in the Cass Report? (Evan Urquhart, Assigned Media, 4/15/24)
• Opinion: England’s Anti-Trans Cass Review Is Politics Disguised As Science (Erin Reed, Erin in the Morning, 4/18/24)
• Dr. Cass Backpedals from Review: HRT, Blockers Should Be Made Available (Erin Reed, Erin in the Morning, 4/19/24)
• The Cass Review, WPATH Files, and the Perpetual Debate over Gender Affirming Care (Julia Serano, Switch Hitter, 4/23/24)
• Misinformation Rampant in Press Coverage of Cass Review (Evan Urquhart, Assigned Media, 4/27/24)
• Methods Change Raises New Questions of Bias in Cass Review (Evan Urquhart, Assigned Media, 5/2/24)
• Social Transition, Puberty Blockers and the Cass Review (Cal Horton on the What The Trans?! podcast, 5/7/24, transcript)
• Cass Says Transition Should Be Measured By “Employment,” Not Satisfaction (Erin Reed, Erin in the Morning, 5/9/24)
• TWIBS: Cas Says Porn Makes You Trans (Evan Urquhart, Assigned Media, 5/10/24)
• Endocrine Society And American Academy Of Pediatrics Respond To Cass, Reject Bans (Erin Reed, Erin in the Morning, 5/13/24)
• Opinion: No, Dr. Cass, Porn Will Not Make You Trans (Erin Reed, Erin in the Morning, 5/15/24)
• The Cass Review Buried Trans Youth Perspectives (Evan Urquhart, Assigned Media, 5/15/24)
• WPATH and USPATH Trash Talk the Cass Review (Evan Urquhart, Assigned Media, 5/18/24)
• NYT Sends Push Review for Anti-Trans Cass Article; Buries AAP Response (Erin Reed, Erin in the Morning, 5/24/24)

The Cass Review Itself

The report is 388 pages long, and available at the link at the beginning of this sentence. It makes 32 recommendations. If you haven’t clicked through some of the above articles, here are some of the most concerning Cass recommendations:

• claims that there is “no good evidence” supporting transgender medical care (wrong!)
  • See a review of over 50 studies by Cornell University
  • Here’s our (incomplete) list of citations supporting adolescent transgender medical care)
  • Julia Serano’s “Gender Affirming Care for Trans Youth Is Neither New nor Experimental: A Timeline and Compilation of Studies,” Medium, 5/16/23)
• supports the “social contagion” theory (ugh. See the Coalition for the Advancement & Application of Psychological Science’s statement and Julia Serano’s excellent article “All the Evidence Against Transgender Social Contagion“)
• non-cis gender identity is caused by anxiety, depression, and OCD (American Psychological Association says “NO!“)
• recommends that puberty blockers should only be accessible via research trials (this is unethical.)
• recommends additional restrictions and roadblocks to adolescent transgender medical care rather than resolving current access issues (…this is also unethical and not supported by the research)
• recommends that care for adults up to age 25 should also be restricted (seriously? Let’s talk autonomy, people!)

Reactions From Major Professional Groups

The WPATH and USPATH Response

WPATH – the World Professional Association for Transgender Health and USPATH – the United States Professional Association for Transgender Health released a joint statement regarding the Cass Review on May 17, 2024. Their concerns include:

• Dr. Cass was charged with leading the care review despite having very little clinical experience in providing transgender healthcare to adolescents.
• Dr. Cass does not have research qualifications or experience in transgender healthcare.
• The conclusions drawn in the Cass Review did not come from any new studies or evidence, yet they are much more conservative than recommendations made by the American Academy of Pediatrics, the Endocrine, Society, and WPATH itself, among others. (Note: WPATH isn’t itself free from criticism that it is too conservative in care recommendations.)
• The Cass Review did not include professionals with experience in transgender health or individuals with lived experience in the process.
• The Cass Review ignores previous evidence reviews and recommendations for care that utilized much broader and more systemic research.
• The recommendation to allow access to puberty blockers in the setting of a clinical trial only is “ethically not feasible.” Quote: There is no role in modern medicine for such practices, which are not commensurate with providing the highest standard of care for young people, as the Cass Review allegedly advocates for.”

European Professional Association for Transgender Health

EPATH statement

“EPATH agrees with much of what Cass recommends, such as a holistic biopsychosocial approach, reducing waiting lists, spreading knowledge, and stimulating more research. EPATH however, also has concerns regarding feasibility of the recommendations, whether it will limit access to care, the weighing of underlying evidence and the ethics of providing care.”

• “In contrast to what the Cass review recommends however, EPATH follows the World Professional Association for Transgender Health’s Standards of Care (SOC8) and considers that the evidence is sufficient to recommend that providing medical affirming treatment including blockers and/or hormones is helpful when indicated, while withholding such treatment may lead to increased gender dysphoria and adversely affect psychological functioning.”
• “EPATH sees at present no evidence, as Cass also acknowledges, that a primary focus on psychosocial care and a restriction of access to blockers and hormones (also for 16/17-year-olds) would be effective in relieving the distress that transgender adolescents and their families may experience”
• “At the same time, however, while waiting for research results, not providing transgender adolescent care that may include puberty blockers and hormones to adolescents who experience gender incongruence is not a neutral act given that it may have immediate as well as lifelong harmful effects for the young transgender person. Also, asking transgender adolescents to participate in research as the only way to receive puberty blockers, as Cass recommends, is unethical. Finally, from a human rights perspective, considering gender diversity as a normal and expected variation within the broader diversity of the human experience, it is an adolescent’s right to participate in their own decision-making process about their health and lives, including access to multidisciplinary transgender health services.” (eff yeah!)

Endocrine Society

Statement From Endocrine Society

Medical evidence, not politics, should inform treatment decisions.

“We stand firm in our support of gender-affirming care. Transgender and gender-diverse people deserve access to needed and often life-saving medical care.

NHS England’s recent report, the Cass Review, does not contain any new research that would contradict the recommendations made in our Clinical Practice Guideline on gender-affirming care.”

A special shout out to Dr. Ruth Pearce’s compilation of Cass Review reaction statements (accessed 5/27/24)

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