What’s wrong with the Cass Review?
The Cass Review, the document that the British government is using to justify curtailing transgender healthcare, is junk.
It opens “this review is not about rolling back people’s healthcare” before discouraging social transitioning and recommending a de facto ban on puberty-pausing prescriptions.
It says that “there should be no hierarchy of gender identity” but habitually privileges cisgender identities over trans identities.
It decries “unmanageably long waiting lists” but the impact of its recommendations has been to drastically increase waiting times for teens who desperately need help.
The British government and press are presenting the review as a smoking gun but it’s more of a wet fart: a flimsy document concocted by a government in the throes of a moral panic. Let’s examine its extensive failings.
Ignorance masquerading as strength
Hillary Cass, the review’s author, is a paediatrician with no trans specific expertise. Her review frames this as an asset:
Given the increasingly evident polarisation among clinical professionals, Dr Cass was asked to chair the group as a senior clinician with no prior involvement or fixed views in this area.
The specious argument being made here is that trans healthcare professionals are biased and their views are thus illegitimate. “Subject matter experts and people with lived experience of gender services” were expressly excluded from the review’s governance committee on these grounds. This is ignorance by choice: it makes about as much sense as choosing a rookie pilot because all of the seasoned captains display a suspicious bias towards altitude.
Inconsistent evidentiary standards
It’s worth stressing that the actual scientific studies that formed the basis of the review are expansive, expensive and (in my view as well as the view of experts), generally quite good: it’s the way that Cass misrepresents them that’s the problem.
Cass sometimes commissions evidence that contradicts her own thesis. She solves this problem by burying that evidence in appendices.
Elsewhere the review discards studies that it considers low quality (an academic term that is better understood as low certainty). This isn’t a problem in itself, the problem is that this level of rigour is not applied uniformly. The review cites various unsubstantiated theories (even positively citing a chapter that promotes pseudoscientific conversion therapies) and these theories are given equal or greater weight than studies that were subjected to the quality assessment process.
The outcome of this inconsistency is a catch 22 for trans healthcare professionals: We deem your research into medical intervention to be insufficient so we’re making recommendations that will hold up further research.
It’s not all Cass’s fault to be fair. Those generally quite good studies that she commissioned? One of them isn’t so great and this leads to a thuddingly obvious double standard. One of the aims of the review was to compare the efficacy of medical and psychological treatments but, strangely, the review applies a completely different assessment methodology to the two approaches. It excludes low certainty medical studies but includes low certainty psychological studies. No rationale is given for this significant protocol deviation. The end result is that the only treatments recommended by the Cass review are supported by the lowest-quality evidence.
Sweeping generalisations and non-evidenced claims
Given how critical the review is of medical evidence, it sure does contain a lot of conjecture.
Whilst some young people may feel an urgency to transition, young adults looking back at their younger selves would often advise slowing down.
This platitude is prominently placed in the review’s executive summary and has been widely celebrated by anti-treatment campaigners. It’s reminiscent of the old saying that: “If you are not a liberal when you are young, you have no heart, and if you are not a conservative when old, you have no brain.” It’s the kind of hokum that yer da might post on Facebook underneath a portrait of Winston Churchill, but it has no place in a nominally evidence-led review.
The implication of the above, that medical intervention is given to gender diverse young people too quickly, is not only unsupported, it’s actively disproved by systematic reviews of existing evidence that Cass herself commissioned. Those reviews showed that 78% of patients received no medical intervention whatsoever and indicated that it actually took many years (wait time ranged from 4-7 years) for young people to access medical intervention.
The review also speculates that young people are coming out as trans due to pressure from their pro-trans peers.
Through adolescence, peers have an increasing influence and parents a lessening influence. Adolescents’ evaluation of their social and personal worth is strongly influenced by what their peers think about them.
This truism, that teens say wacky things to fit in, is the linchpin of Cass's argument, but the review provides no evidence to support it. There’s a wealth of evidence to the contrary (transphobic hate crime reached record highs last year and 34% of Brits now describe themselves as prejudiced against trans people) but these inconvenient facts don’t get a mention in the review.
The review does this time and time again: misinterpreting data, mishandling evidence and resting its conclusions on speculation. Reading it in the context of rising transphobia in the UK is enough to make you feel like you’re going mad. Cass seemingly exists on a different planet to the trans people she’s making decisions on behalf of.
Concealed collaborators
When Cass speaks to trans supportive sources they tend to get namechecked in the review. This is both ethical and, given Cass calls for restrictions on gender-affirming care, a useful shield from criticism.
Cass doesn’t disclose her anti-treatment sources to nearly the same extent. For example she obliquely refers to “meetings with international clinicians & policy makers”, but it’s only thanks to recently submitted court exhibits that we know Cass collaborated with Ron DeSantis’s handpicked Board of Medicine in Florida. Her review is now being used in states across America to support bans on gender-affirming care for young people.
Concealed prejudices
Why, you might be asking, did Hillary Cass put her name to a review that has been so thoroughly and embarrassingly debunked? Paper after paper after paper, and now even the British Medical Association, have criticised her work yet she unwaveringly stands by it . It’s not the kind of behaviour you’d expect from “a senior clinician with no prior involvement or fixed views in this area”. The answer offered by her colleagues is that her claim to be a neutral outsider is untrue. They say Cass was:
Known by colleagues to oppose medical transition when she was appointed to the review [and] expressed her dismay and shock at the practice of medical transition
This makes sense to me. I find the idea that anyone in British civil society can hold no views on an issue as over-discussed as trans people to be implausible. To be clear if what her colleagues say is true, then Cass concealed her own views while using the expressed views of others as grounds to exclude them from participating in her study. This is scandalous stuff that Cass’s team has, thus far, not responded to requests for comment on.
In the context of apparently concealed prejudice, it’s worth asking whether Cass’s claim that her work constitutes an “independent review” really stands up. That she was the only person ever considered by the government to chair the review is suspicious, and looks worse given what we’ve learned about her prior views. Kemi Badenoch gave the game away when, writing in her capacity as Minister for Women and Equalities, she took a victory lap:
England has taken a global lead when it comes to banning puberty blockers for children confused about their gender. The reason [that this happened] was having gender-critical men and women in the UK government, holding the positions that mattered. The Cass Review would never have been commissioned under a Labour govt.
A review is, by definition, not independent if it never would have happened under a different benefactor. The closeness of their relationship was further driven home when, shamelessly, they rewarded her with a job for life in the House of Lords.
A call to action
So what can fair-minded people who want trans folks to receive excellent healthcare and be treated with dignity do about all of this?
We must keep up the hard work of campaigning and explaining. The government wants to treat the Cass review as a black box that they can point at and say: We’re implementing these recommendations and you can’t hold us accountable for the outcomes because we’re doing it on doctor’s orders. The act of reading and rebuking this review pries open that black box, shines a light on its rotten innards and makes it impossible for the government to use it as an accountability sink.
If you live in the UK you can write to your MP pointing out that a new government has the opportunity to reject this deeply flawed document, moving away from gender critical posturing to a more balanced, person-centred and genuinely evidence based view of trans healthcare.
If you don’t live in the UK then I’m very sorry that you have to deal with our transphobic exports, but you can still campaign against this miserable review whose impact is already being felt around the world.
Acknowledgements
The Cass review has provoked an enormous amount of comment for a piece of healthcare literature. Rightly so: it’s a staggeringly flawed document that’s being used by a new British government to pursue the same harmful policies that the last lot were. When pressed on this fact, the government offer a rehearsed non-answer, so it’s no wonder that critics of the review have started loudly campaigning about how flawed it is. This post is indebted to those campaigners. Their work is a triumph of reality over mystification.
Gideon Mayerowitz-Katz’s eight-post marathon (once you start writing about how bad this review is it’s very hard to find the off-ramp) is the best source for documentation of the factual errors made by the review.
Michael Hobbes and Aubrey Gordon’s recent run of Maintenance Phase episodes are what turned me onto this topic in the first place. A good humoured and effective explainer:
If you’re up for reading scholarly work then Critically Appraising the Cass Report, An Evidence-Based Critique of the Cass Review & Cass: the good, the bad, the critical are worth your time.
If, like me, you enjoy the feeling of exasperation and do not value your time, you can read the Cass review here.
Beautifully written and thoughtfully put together. Thank you.