The Cass Review
The Tyranny of LGBT+ Stakeholder Politics
Dr Hilary Cass, an eminent consultant paediatrician with no prior involvement in paediatric gender medicine, was commissioned in 2020 by NHS England to carry out an independent review of the Tavistock NHS Hospital Trust’s Gender Identity Development Service (GIDS). Her Interim Report declared the service unsafe, advised that multiple, smaller regional centres would replace it utilising “a fundamentally different service model … more in line with other paediatric provision”. Many of us breathed a sigh of relief: “The Tavistock is closing!”; “Cass has proved us right, and our work to safeguard children from social and medical transition is done!”.
I was delighted by the direction of travel of the Interim Report. Cass says that although she and her team are “cognisant of the broader cultural and societal debates relating to the rights of transgender adults”, they take no “position on the beliefs that underpin these debates”. The Report is “strictly focused on the clinical services provided to children and young people who seek help from the NHS to resolve their gender-related distress”. In particular, Cass does not use the term “the trans child” but children who are “gender-dysphoric”. Although the latter term is problematic, a point to which I will return shortly, nevertheless its use destabilises the GIDS narrative derived from postmodern queer theory.
Sadly, I am about to cast a shadow over the current celebratory mood. I now fear that our optimism may have been naïve that the new regional centres will put an end to medical malpractice. The questions I now ask are the following: Is it possible, despite Cass’s best and most honourable intentions, for the new centres not to be shaped by the ideas that underpin debates about the rights of transgender adults? Will the more cautious policies she proposes be sufficient to expel transgenderist politics from clinical care?
I answer these questions by addressing Cass’s recent refinement of the Interim Report. In response to a consultation with “NHS England, providers and the broader stakeholder community … to understand their perspectives” Cass tells us she has made two observations and some substantive changes. Her Final Report is due later this year.
Two General Observations about the Interim Report
Cass’s first observation is that the regional centres must “ensure that children, young people and their families are kept central to any approach”. I’m unsure what she means since it is established orthodox practice that children and their parents/ caregivers are the focus of paediatric medical care. Does she mean that parental perspectives on the aetiology of gender dysphoria and its treatment will be kept central to any clinical approach?
The consultation will have considered the views of families who believe that gender identity is inherent and that the social and medical transition of children who have a “transgender identity” is the best option. This view is promulgated by Mermaids, Stonewall, and the lesser-known Gendered Intelligence which lauds its approach to sex and gender as a revolutionary epistemic paradigm shift in knowledge underpinned by the postmodern, queer theorist Judith Butler. Collectively these groups reverse the conventional meanings of sex and gender. They claim that biological sex difference is culturally “assigned” at birth and that gender identity is immutable. They have lobbied intensively for children’s rights to be offered puberty blockers so that their outer bodies can match their authentic inner selves. Most families which sought support from the GIDS understand “transgenderism” through this conceptual framework, whether or not they have even heard of queer theory.
Lobby groups have far wider goals than representing what they allege are children’s healthcare needs. Mermaids and Gendered Intelligence, for example, became charities that earn money through LGBT+ awareness training, including in schools for teachers and pupils. Gendered Intelligence has lobbied for reform of the GRA 2004 in England and Wales, according to the principles embodied in the Gender Recognition Reform Bill recently passed by the Scottish Parliament. It has also lobbied for reform of the Equality Act 2010 to remove single-sex exceptions for women in prisons, female-only changing rooms and so on. In other words, the view that gender identity is inherent and immutable in children is inextricably bound with debates about “the rights of transgender adults”.
Cass’s second general observation, having considered the perspectives of the broader stakeholder community, is that there was “linguistic confusion” in the Interim Report and that “more clarity would help to move away from artificial binary opposition between exploratory and affirmative approaches and breakdown the ideological tensions”. Cass’s hope that this binary can be avoided in the regional centres and replaced by a more nuanced approach is optimistic, given that powerful stakeholder groups within the NHS are entrenched in a belief that anything other than unconditional affirmation is transphobic.
Dr Michael Brady, for example, the Government’s National Adviser for LGBT Health, has consistently given thanks to Mermaids for the support it offers “trans, non-binary and gender diverse children and young people and their families”. He presumes that conversion therapy is an ongoing harmful practice in the NHS and describes it as an “abhorrent practice” that “preys on the vulnerable and leads to long-lasting harm”. Another example is that of a UK Medical Schools Charter against so-called conversion for “trans people” which has recently been created in partnership between Lancaster University Medical School and GLADD, an organisation that represents LGBTQ+ doctors and medical students. To date, 40 medical schools out of 45 have signed it.
Substantive Changes to the Interim Report
Cass now proposes a number of substantive changes to the Interim Report, two of which are the following. First, after consultation she now realises that the “references to social transition are a cause for concern”. She had originally claimed that to facilitate social transition is “not a neutral act” and can have a significant impact on children’s “psychological function”. She is now keen to reassure that the comment on social transition “is not a statement about wider society” and that the regional centres will not impose any such view. Decisions about social transition will be “individual”, and the “agency” to make them “will ultimately rest with the young person, along with their family/ carers”. However, where there is “any clinical involvement with the decision-making process” about social transition “the risks and benefits” will be discussed carefully, referencing “best available evidence”.
The consultation will no doubt have heard from parents who believe in Cass’s initial statement. Such parents are “very cautious about clinical approaches, school guidelines, public policy, consumer messages and law that make trans identities in the young 'a phenomenon'”. The over 3,500 children and young people currently on the waiting list for support services suggests there is merit to their view that the exponential rise in children identifying as “trans” is a temporal response to a range of developmental, mental health, and social factors. Notwithstanding, the view that “transgender” identity is inherent has become hegemonic and any reasoned critique or analysis is often viewed as transphobic or bigoted. The Interim Report, in pulling back from its clear assertion that social transition is not neutral, seems to succumb to the sensibilities of those families and lobby group stakeholders wedded to the idea that “transgenderism” exists independently of social context.
Second, Cass now states it is crucial that “appropriate training and development initiatives are available to support the existing workforce” if the regional centres are to be “embedded within a broader child and adolescent health context”. This leaves open the issue of which providers will be deemed capable of delivering such training and it also begs the question of which “gender specialists” will be chosen from the existing workforce.
The Tavistock has confirmed that the GIDS will work closely with commissioners of the new service to ensure a smooth transition to the new model of delivery. It is not yet clear whether Polly Carmichael, the current Director of the GIDS, will have a significant role, but here are her most recent views. She has signed an open letter objecting to the position statement made in response to the Interim Report by ACP UK, the professional body for clinical psychologists. Along with other “gender identity specialists” from the GIDS, including stakeholders with “LGBT experience” and “community members who represent trans and non-binary voices” Carmichael et al object to the use of the term “gender dysphoria” by ACP UK as “medicalising language”. They suggest “‘gender questioning’ or ‘gender diverse’ as more neutral, descriptive terms”. They also object to the “use of ‘male’ and ‘female’ because these terms undermine the lived experiences of some children and young people”. They assert that “the more accurate, terminology is ‘assigned (assumed) male at birth’ or ‘assigned (assumed) female at birth’, reflecting that people may now identify with genders that are different from their assigned sex”.
Will the existing workforce be able to work with the concept of “gender dysphoria” a term the GIDS defined as pathologising? Their affirmation of the “trans child” had resulted in a situation whereby virtually any body modification desired by a young person, including unlimited possibilities for “nonbinary” procedures, could be considered “medically necessary”. Will they now be willing or capable of enabling young people and families to make better-informed decisions about medical transition by disclosing the profound uncertainties regarding the outcomes of the treatment pathway which they have once passionately advocated?
Cass has now stated that, unlike the GIDS, a medically qualified doctor will be appointed as part of the workforce because of challenging decisions about life-changing medical interventions. The introduction of a physician promises, on the face of it, to bring a grounded, evidence-based perspective that biological sex is not “assigned”. The aspiration for clinical objectivity is laudable but perhaps unrealistic, given that doctors who are attracted to paediatric gender medicine may also believe that gender identity is an inherent and immutable phenomenon for which medical transition is the best option.
Additionally, unlike other conditions which physicians deem necessary, “gender dysphoria” is self-diagnosed by the patient, in this instance a child.
The consent of children and young people to medical treatment is impossible since it requires the ability to weigh up evidence for the efficacy of puberty blockers, and to comprehend the immediate and long-term consequences (which some clinicians have ostensibly found difficult). It also requires children and young people to understand that statistically they will be most likely to proceed to cross-sex hormones and surgery with life-changing consequences, including sterility and lack of sexual function, areas of life which, as yet, they can have no comprehension. Any medical transition that medical doctors may action in the new centres, albeit with extra checks and balances, will thus reproduce LGBT+ normative tenets and social justice ethics.
Lastly, Cass has consulted with NHS England about its perspectives on the Interim Report. I argue that any perspectives must be put into the context that the NHS is an institution which is already ideologically captured. NHS England describes the signs and symptoms of teenage gender dysphoria as a “strong desire to hide or be rid of physical signs of your biological sex, such as breasts or facial hair” and/ or “a strong dislike of the genitals of your biological sex”. This condition should not be named gender dysphoria but body dysmorphia, a mental health issue which surgery will compound rather than alleviate. Phalloplasty is provided for young women over 18 years as a core component of the NHS gender identity care pathway. Currently there are approximately 2,000 young women on the waiting list for the one hospital in the UK which performs it. Although there is unprecedented pressure on an already stretched and underfunded NHS, a freedom of information request reveals that the NHS is paying for two new hospitals as well phalloplasty training for surgeons.
The Care Quality Commission (CQC), which regulates all health and social care services in England, and thus will regulate the new regional centres, is a Stonewall Champion. Dr Navina Evans, the Chief Executive of Health Education England (HEE), the proud recipient of a gold award from Stonewall, comments that in contrast to “increased hostility towards LGBTQI+ charities and Stonewall”, many health and care organisations in the NHS have found Stonewall helpful. HEE guidance suggests all staff lead the way on being “a trans ally” by introducing themselves with their pronouns and supporting “trans people’s” choice of bathroom “that corresponds to their gender identity”.
There is a partnership between NHS England, NHS Improvement and the Health and Care LGBTQ+ Leaders Network whose remit is to improve the experience of LGBTQ+ staff and patients and to increase LGBTQ+ representation in senior leadership to influence change across the system. Lastly, GLADD, the organisation that represents LGBTQ+ doctors and medical students, insists that the LGBTQ+ community faces more challenges and barriers to accessing healthcare than the general population. It has a national voice in LGBTQ+ health activism and education, working with leading figures such as the British Medical Association, General Medical Council, Royal Colleges, and Parliament.
I suggest that the bodies and networks to which medical students, doctors, and senior leaders belong in the NHS will have wide ranging abilities to chip away at any service specifications proposed by Cass.
In conclusion, Cass has been handed an extremely difficult task. Her goal to separate the political from the clinical is already proving pervious to transgender politics. Until publicly exposed by The Telegraph, the South London and Maudsley NHS Hospital Trust which had been specifically designated as a centre taking over specialist mental health support from the GIDS, commissioned Mermaids to provide sessions on “ LGBT+ awareness training”. The Trust’s intended employment of Mermaids, despite the fact Mermaids is currently under investigation by the charity regulator and has been deemed instrumental in helping create the unsafe service model of the GIDS, points to a much larger malaise deep at the heart of paediatric gender medicine. What is at stake is not lack of science or bad science, issues of course which are of the gravest importance, but that the success of the LGBT+ paradigm of thought has made medical intervention on the completely healthy bodies of children not only “thinkable” but a matter of “social justice”. Like Hydra, the Greek mythical monster whose multiple heads, if lopped off, had the power of regeneration, the unevidenced but unwavering faith in the “gendered soul” and the medical malpractices which result may not yet be quelled by the closure of the Tavistock GIDS but live on in the reformed regional centres. Only time will tell.