THE CASS REVIEW
REASON PREVAILS OVER PREJUDICE AFTER 20 YEARS
THE APPEARANCES SOCIETY
Dr. Hilary Cass released her Independent Review of Gender Identity Services for Children and Young People in the second week of April, causing a tremendous impact on the UK. The review had been commissioned by the National Health Service (England) (NHS) to make recommendations on these services.
The review caused a tremendous impression for at least four reasons. First, it demolished the ideas that had been considered established science in this area for about two decades and, with them, it disqualified the practices that had been the basis of the mentioned services during that period. Second, despite the radical posture of the review, no one has dared to challenge its results, even if only one day before the publication negating the ideas that the review demolished would have attracted massive attacks in the social networks and otherwise—just as J. K. Rowling could testify. Third, the review’s recommendations were immediately adopted and included in the constitution of the NHS. Fourth, politicians, celebrities, and gurus who had supported the demolished ideas stayed quiet or reversed their positions, pretending that they had not said the things they had publicly stated.
These events attest to the scientific solidity of the review. They also posed a question. The main finding of the review was that there was no scientific basis for the diagnoses and the treatments that the NHS was providing to children and young people who felt they had gender dysphoria—that is, the feeling of deep unhappiness and dissatisfaction with one´s gender. Moreover, it says that NHS was not correctly evaluating the risks that the treatments it was prescribing for the youngsters—like puberty blockers and other interventions, many of them irreversible—and that in many cases such treatments did not only fail to improve the youngsters’ psychological and medical conditions but worsened them. If this was the case, and it was, the question that begs an answer is, why did these ideas now deauthorized become the accepted wisdom, not only through social networks but also in a prestigious institution like the NHS?
The question becomes more poignant because Tavistock, the NHS trust now at the center of the scandal, included the following paragraphs in a funding application submitted in 2019:
‘The adoption of a medical treatment with uncertain risks, based on an unpublished trial that did not demonstrate clear benefit, is a departure from normal clinical practice.’
…
‘There is minimal research evidence to inform questions regarding likely trajectories and outcomes particularly in the context of: a) physical treatments (e.g. hormone blockers to suppress the onset of puberty); b) social transition (where a child presents to other people as their experienced gender e.g. using preferred gender pronouns) and; c) co-occurring ASD [Autistic Spectrum Disorder].’[1]
That is, Tavistock knew five years ago that the scientific evidence supporting its prescribing treatments was weak or non-existent. If this was so, it had to have been even worse when it started to prescribe them more than a decade before. And, after saying this in 2019, it continued to prescribe them. As reported by The Telegraph, the application was approved by the National Institute for Health and Care Research along with a study by Oxford University which “built upon critical race scholarship to develop a theory of how ‘cis-ignorance’ manifests in trans healthcare…”[2] The project was completed in 2021. Still, there are no resulting publications on the NIHR’s website.
Nurse Sue Evans had raised concerns as far back as 2004.
“When Evans started at the Tavistock in 2003, she was “proud to be working in a tiny team at a pioneering organisation”. But on hearing a colleague describe how, after only a few assessments, they had referred a distressed 16-year-old boy who thought of himself as female for hormone treatment, her “jaw dropped”. She recalls feeling ‘something was very, very wrong with the GIDS approach’.”[3]
Many years later, Sue Evans supported an application for judicial review into whether NHS procedures were unlawful. The application was presented by Keira Bell, 23, who had started taking puberty blockers when she was 16, before undergoing reassignment surgery, and now regretted having done so, and by “Mrs. A”, the mother of a 15-year old girl on the waiting list for treatment.
Susan Evans was afraid of the result of this process.
“I was told privately by some the case was hopeless, that the bar had been captured by transgender activists, that institutions had been captured by ideologically driven charities,” says Evans. “Certain trans groups have really cultivated an atmosphere of fear among children and their families. But I’m just very relieved and obviously pleased with the ruling.” [4]
Evans is relieved because three High Court judges ruled in 2020 that children under 16 cannot give informed consent. This put an “immediate end to the use of drugs that delay the development of sex organs by blocking the hormones testosterone and estrogen, but which can have serious side effects and unknown longer-term consequences”.[5]
Keira Bell had a double mastectomy aged 20, and now regrets transitioning, which has left her with “no breasts, a deep voice, body hair, a beard, affected sexual function and who knows what else that has not been discovered”. She may well be infertile as a side effect of the drugs.[6] “Mrs. A” got judicial support to prevent her daughter from making a similar mistake.
These stories seem to have been taken from a dystopian novel. Yet, they were taken among many from the real world.
THE CASS REPORT
In this section, I quote directly from the Cass Review. The numbers in paragraphs correspond to the numbers assigned in the report. The quotations include parts or the whole of those paragraphs.
“6. When the Review started, the evidence base, particularly in relation to the use of puberty blockers and masculinising/feminizing hormones, had already been shown to be weak.
8. To scrutinise the existing evidencethe Review commissioned a robust and independent evidence review and research programme from the University of York to inform its recommendations and remained cautious in its advice whilst awaiting the findings.
9. The University of York’s programme of work has shown that there continues to be a lack of high-quality evidence in this area and disappointingly, as will become clear in this report, attempts to improve the evidence base have been thwarted by a lack of cooperation from the adult gender services.
13. There remains diversity of opinion as to how best to treat these children and young people. The evidence is weak and clinicians have told us they are unable to determine with any certainty which children and young people will go on to have an enduring trans identity.
Key Points
Regarding the benefits of the intervention programs based on puberty blockers:
“22. Preliminary results from the early intervention study in 2015-2016 did not demonstrate benefit. The results of the study were not formally published until 2020, at which time it showed there was a lack of any positive measurable outcomes. Despite this, from 2014 puberty blockers moved from a research-only protocol to being available in routine clinical practice and were given to a broader group of patients who would not have met the inclusion criteria of the original protocol.”
Interim Report
25. In 2022, the Review published an interim report, which provided some initial advice. It set out the importance of evidence-based service development and highlighted major gaps and weaknesses in the research base underpinning the clinical management of children and young people with gender incongruence and gender dysphoria, including the appropriate approaches to assessment and treatment. Critically, the interim report highlighted that little is known about the medium- and longer-term outcomes for children and young people receiving NHS support and/or treatment.
47. The World Professional Association of Transgender Healthcare (WPATH) has been highly influential in directing international practice, although its guidelines were found by the University of York appraisal process to lack developmental rigour.
Diagnosis
58. Although a diagnosis of gender dysphoria has been seen as necessary for initiating medical treatment, it is not reliably predictive of whether that young person will have longstanding gender incongruence in the future, or whether medical intervention will be the best option for them.
Psychological interventions
67. The systematic review of psychosocial interventions found that the low quality of the studies, the poor reporting of the intervention details, and the wide variation in the types of interventions investigated, meant it was not possible to determine how effective different interventions were for children and young people experiencing gender distress.
5.66 Although the suicide rate in the gender-referred youth was higher than in the general population, this difference levelled out when specialist-level mental health treatment was taken into account. Overall, it is difficult to draw firm conclusions because the absolute risk of suicide in the population of gender dysphoric youth and in the control population was very low, so numbers were thankfully small.
Medical pathways
80. The original rationale for use of puberty blockers was that this would buy ‘time to think’ by delaying onset of puberty and also improve the ability to ‘pass’ in later life. Subsequently it was suggested that they may also improve body image and sychological wellbeing.
81 The systematic review undertaken by the University of York found multiple studies demonstrating that puberty blockers exert their intended effect in suppressing puberty, and also that bone density is compromised during puberty suppression.
82. However, no changes in gender dysphoria or body satisfaction were demonstrated. There was insufficient/inconsistent evidence about the effects of puberty suppression on psychological or psychosocial wellbeing, cognitive development, cardio-metabolic risk or fertility.
83. Moreover, given that the vast majority of young people started on puberty blockers proceed from puberty blockers to masculinising/ feminising hormones, there is no evidence that puberty blockers buy time to think, and some concern that they may change the trajectory of psychosexual and gender identity development.
84. The Review’s letter to NHS England (July 2023) advised that because puberty blockers only have clearly defined benefits in quite narrow circumstances, and because of the potential risks to neurocognitive development, psychosexual development and longer-term bone health, they should only be offered under a research protocol. This has been taken forward by NHS England and National Institute for Health and Care Research (NIHR).
85. The University of York also carried out a systematic review of outcomes of masculinising/feminising hormones. Overall, the authors concluded that “There is a lack of high-quality research assessing the outcomes of hormone interventions in adolescents with gender dysphoria/incongruence, and few studies that undertake long-term follow-up. No conclusions can be drawn about the effect on gender dysphoria, body satisfaction, psychosocial health, cognitive development, or fertility. Uncertainty remains about the outcomes for height/growth, cardiometabolic and bone health. There is suggestive evidence from mainly pre-post studies that hormone treatment may improve psychological health, although robust research with long-term follow-up is needed”.
86. It has been suggested that hormone treatment reduces the elevated risk of death by suicide in this population, but the evidence found did not support this conclusion.
87. The percentage of people treated with hormones who subsequently detransition remains unknown due to the lack of long-term follow-up studies, although there is suggestion that numbers are increasing.
88. A problem, that has become increasingly apparent as the Review has progressed is that research on psychosocial interventions and longer-term outcomes for those who do not access endocrine pathways is as weak as research on endocrine treatment.
Long-term outcomes
89. One of the major difficulties with planning and evaluating gender identity services for children and young people is the very limited evidence on the longer-term outcomes for people who have accessed GIDS [Gender Identity Development Service]. Although retrospective research is never as robust as prospective research, it would take a minimum of 10-15 years to extract the necessary follow-up data
WHY?
John Armstrong from Cambridge University identified the erosion of academic freedom in British universities as the central reason for these dystopian events.[7]
Any academic who dares to question gender-identity orthodoxy can expect obstacles at every stage of the research process. #e ethics committee at Bath Spa University blocked research into detransitioning among young people because ‘Engaging in a potentially “politically incorrect” piece of research carries a risk to the University.’
A study that raised the hypothesis that social contagion might be a factor in rising admissions to gender-identity clinics was denounced as “hate speech”. Papers have been rejected because they talked about biological sex. James Esses was sacked from his master’s course because he argued that gender-questioning children should receive counseling rather than being put in a medical pathway; police advised Kathleen Stock to stay away from campus for arguing for ideas now contained in the Review; and so on. Interestingly, James Esses was expelled from his master’s course for arguing something that the Cass Review validated in paragraph 5.66 above when saying that psychological treatment leveled the statistical difference between the suicide rate of youngsters with dysphoria and the rest of the youngsters’ population.
What was happening in the universities was happening all over the place. Principals and teachers in schools decided to refer the children as of the opposite sex without informing their parents and created an environment favorable to medical treatment.[8] It was happening in social networks, newspapers, and electronic media.
Armstrong is certainly right to signal the erosion of free speech as a central reason for the prevalence of prejudice over reason in even some of the best universities in the world and prestigious government institutions. Yet, this poses another, more fundamental question: Why is free speech being eroded in those institutions and the rest of society?
This question is especially interesting because the repression of free speech does not seem to have expanded from the learning institutions to the rest of society; instead, it is in the opposite direction. As Susan Evans thought,
“The real scandal is that the treatment pathway of children with gender dysphoria became ever more politicised, and moved away from high standards of clinical mental healthcare with good assessment and psychotherapeutic treatment.”[9]
That is, the prevalence of prejudice and repression of free speech extended from the political environment toward universities and professional government institutions, which are supposed to be guardians of objectivity and reason. Moreover, this is happening in many other dimensions of reality, from intellectual snobbism (don’t you ever mention some subjects that are out of fashion or express doubts about wonderful ideas) to dark pressures to ensure the political prevalence of certain political trends.
This is the question we must understand before it destroys Western civilization.
--------
Manuel Hinds is a Fellow at The Institute for Applied Economics, Global Health, and the Study of Business Enterprise at Johns Hopkins University. He shared the Manhattan Institute's 2010 Hayek Prize and is the author of four books, the last of which is In Defense of Liberal Democracy: What We Need to Do to Heal a Divided America. His website is manuelhinds.com
[1] John Armstrong, Why academia failed to challenge trans ideology, The Spectator, 13 April 2024, https://www.spectator.co.uk/article/why-academia-failed-to-challenge-trans-ideology/
[2] Ibid.
[3] Josephine Bartosch, Why I was right to blow the whistle on the Tavistock Clinic over puberty blockers, The Telegraph, 5 December 2020, https://www.telegraph.co.uk/health-fitness/body/right-blow-whistle-tavistock-clinic-puberty-blockers/
[4] Ibid.
[5] Ibid.
[6] Ibid.
[7] John Armstrong’s análisis is summarized from The Telegraph’s article quoted in footnote 1 above.
[8] Anonymous author, ‘Websites tell my gender dysphoric daughter where to get testosterone—it’s grooming’, The Telegraph, 5 December 2020, https://www.telegraph.co.uk/family/life/websites-tell-gender-dysphoric-daughter-get-testosterone-grooming/
[9] Ibid, footnote 3.