conversion therapy

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My speech on the Cass Review and Scotland’s trans healthcare ban (with footnotes!)

This post shares a video and transcript of my speech at the emergency demonstration in George Square, Glasgow, on 18 April 2024, against the decision from NHS Greater Glasgow and Clyde to ban endocrine treatments for trans people aged under 18. The speech was unplanned and made without notes, so I have made some small corrections in the transcript, plus minor amendments for clarity. I have also added references for some key points. Thank you to @transprotestglasgow for the video.

Readers seeking more detailed evidence and academic critiques may find my previous blog post helpful: What’s wrong with the Cass Review?

TRANSCRIPT

Hi, I’m Ruth Pearce.

I’m a Lecturer in Community Development at the University of Glasgow, and I’m a researcher on trans healthcare.

And I was a trans child.

I want to talk about that for a moment. Because I came out to myself circa 2001, when I was 15, when not many people did that. And it was hard for us. And there was trans community, and there was information, but it was very difficult because we felt very, very alone. I was mostly only able to connect with other trans people my age through the internet, through blogs, and they were mostly Americans. The Brits were there; a lot of us connected later as we grew older. But we were so isolated.

A really important thing to remember, in a moment like this where we are seeing a return to the kind of medical policies that were in place when I was a kid: there are so many more of us, and we are so much more powerful than we have ever been.1 Never forget that strength we have together.

One of the things Hilary Cass says in her report is that the meaning of the word “trans” has changed since 2020.2 She says, and there is no evidence for this, that “trans” in 2020 meant something quite rigid and specific, and only now in 2024 it’s become an umbrella term for lots of identities. Tell that to me coming out as a trans teenager in 2001!

So here’s the thing. We’ve always been here, and we are more powerful now, but we are seeing this backlash. That’s been a long time coming and transphobia changes its face over time. One of the things I wanted to do to deal with my loneliness and the experiences I had was that I wanted to become an activist. And when I started doing activism, when I got into meetings with people in government, and with the Equality and Human Rights Commission, they said “there’s no evidence” for the discrimination we faced. So I was like, “fine: let’s see what evidence I can find”.

So I did a PhD in trans healthcare.3 And I found what you often find when you do research; you often find things you don’t expect. So I did find some things I expected to find. About waiting lists and how hard they are. About how hard appointments can be when you’re meeting with sexist and transphobic clinicians who are asking you, as a young person, how you masturbate and who you’re attracted to. But what I didn’t expect was the sheer level of pain from the waiting. And I talk about that in my work. And the anticipation, where we are anticipating all the time. When is it going to happen? When are we going to get to live our lives? And that happens on every level of our lives.

I was also shocked by the level, and detail, and complexity of the ignorance of healthcare practitioners. It ranges: it’s not just that they all hate us, right? It’s that some people are trying to control us, some people want to help but don’t understand how, and some people don’t want to know. There’s different kinds of ignorance.4

So I published my work, and other people have followed. Other people were there before me of course, because “trans” was not new, and trans research wasn’t new either. There is now a lot of published research on what it is like to go through a gender clinic, and what it is like for a young person to go through a gender clinic. There’s people like Cal Horton5 and Natacha Kennedy6 who are writing on this, and Harvey Humphrey7 who works here in Glasgow. There’s a lot of people doing work on this.

We are saying, time and time again, “we need services that meet our needs”. For some people, that is access to puberty blockers, and that is access to hormones. For other people, that is access to counselling, and therapy, and community support. What we call “trans-affirmative” or “gender-affirmative” care is flexibility, meeting a person where they are at, and based on what they want to do with their lives.8 You don’t have to change your body – but you can.

It’s our body, it’s our right: we can do what we want with our own bodies.

This is what is disgusting about the decision by NHS Greater Glasgow and Clyde. They have not addressed the years and years of mistreatment and abuse in their child and adolescent clinic at Sandyford. It is not a great place that we are trying to save. It is a clinic that has repeatedly refused to treat young people, and made people hold on for care. It has helped a handful of people. Dozens of people – only dozens – have accessed treatment in the last few years.9 Now they are proposing to stop doing the very little they are doing to support young trans people.

People who get a referral to a child and adolescent gender clinic are not necessarily seeking access to counselling and therapy, because you can get that elsewhere.10 They are not seeking access to community, because you will find no community at Sandyford. They are most likely seeking access to endocrine treatments: puberty blockers and hormone therapy. And that’s what they are going to stop doing.

Sandyford say they are still accepting new referrals. But what is the point of a gender clinic that does not offer people medical treatment?

NHS Greater Glasgow and Clyde have based their decision on the final report of the Cass Review. Let’s talk a bit about the Cass Review.

I’m an academic researcher. If the Cass Review was submitted by an undergraduate student, the first thing I would say is: “That’s nearly 400 pages long! No-one’s going to have time to mark that”.11 And you’ll notice that all the people in the media, all the Labour politicians, all the Tory politicians, all the people saying we should immediately implement the findings of the report: none of them read nearly 400 pages in one day. Neither did the journalists at the BBC, the Telegraph, the Times, the Daily Mail, the Observer, the Independent. We expect better! And now the Scottish media: it’s all over the Scotsman, the National, the Herald. None of them have bothered to read the report, or think about it critically.

So here’s a bit of information about the Cass Review. The Cass Review was undertaken by a group of people who, from the very start, excluded trans people from oversight of the project. That was in their terms of reference.12 They didn’t want people who had experienced services having a formal part in the report. They excluded healthcare experts. If you were someone who had worked in a gender clinic you were excluded from being part of that.13 You know, I have lots of disagreements with many people who work in gender clinics, but you would have thought they might get a say.

You can see that ignorance, that intentional ignorance, playing out in the final report of the Cass Review. You can see, if you read the Cass report, that they looked at over 100 studies, most of which show that puberty blockers and hormone therapy can help young trans people. And they just ignored them.14 Intentionally. They say that the majority were not “high quality evidence”.15

What else is not high-quality evidence in healthcare? Paracetamol for back pain.16 There is no high quality evidence for that, in the terms of the Cass Review. Anti-psychotics.17 ADHD medication.18 All these medications that are in regular use. You know what else? Puberty blockers for young people with precocious puberty – if they’re cis.19 That is direct discrimination. 20

The thing is, that’s the Cass Review being serious. Let’s think about when it gets weird.

There’s a graph in there, where they show referrals to a gender clinic (the Gender Identity and Development Service in England) rising year on year, with “an exponential rise in 2014”. But they cut the graph off at 2017. But if you look at 2017-2020 the referral rate flattens off. It’s deliberate removal of evidence.21

We know why this is happening. Experts – medical experts, and experts by experience have been cut out of the Cass Review process. If you are trans, that’s you. You are an expert by experience. You know what it’s like. We have been cut out the process!

And the NHS have done that here in Scotland. There was no consultation on the ban that’s come in.

Who did they consult? We know there are people who are proponents of conversion therapy who were on the Cass Review team.22 That is what they are proposing.

They are proposing conversion therapy. Not just for trans kids, because they want to deal with all gender-questioning and non-conforming kids. This is going to be conversion therapy for queer kids. Little boys who want to wear a dress, they might not be trans, but they deserve to have the space to explore. That is not going to be what happens in clinics where people are referred which are being informed by conversion therapists.23

So consequently you have other weird stuff in the Cass Review. They’re dismissing all the evidence about why puberty blockers and hormones can benefit people within particular contexts, but they’re relying on other evidence for their recommendations. Let me give you one citation. “Thoughts on Things and Stuff, 2023”. That is a citation from the Cass Review: Thoughts on Things and Stuff.24

What is “Thoughts on Things and Stuff”? It’s a right-wing Youtube channel run by anti-trans bigots,25 featuring contributors such as “Gays Against Groomers”.26 This is the level of evidence that is informing NHS Greater Glasgow and Clyde.

And I’ll tell you what else is in the Cass report. They say that little girls are likely biologically inclined to play with dolls. It’s right in there, in the Cass report.27 And little boys are probably biologically inclined to play with trucks. Why is this? It’s not just an anti-trans agenda. It’s an anti-feminist agenda. Its an anti-woman agenda.

Why is this happening? It’s happening because trans people are an easy target.

If you want to stop young people accessing contraception as teenagers, you remove trans people’s right to consent to care as young people. If you want to prevent young people – teenage girls – from having abortions, and you’re failing time and time again in the courts, you instead target puberty blockers, because that way you can set a precedent for preventing people from being able to make decisions as young people. You are undermining the idea that young people might have the capacity to consent to care and make an informed decision about their own bodies.28

So I will end on this. I’m a woman, I’m a trans person, and I think it’s really important we think about allies. I had the parent of a trans child contact me and say, “thank you for being an ally”. I want to think her for being an ally. The thing about allies is, we talk a lot about an “ally” being someone who supports somebody else. But no: allies are people who stand by each other and work together.

That’s why we need a trans feminist movement. A trans feminist movements gives people autonomy over their own bodies, space to make their own decisions, and enables people to stand together when we are all at risk.

So I’ll leave you with a chant I want to hear more of at protests:

“Trans rights, women’s rights: one struggle, one fight”.

FOOTNOTES

  1. My statement here is intended to highlight that more people are out as trans than ever before. Contrary to narratives of “social contagion”, there have always been people with gender diverse or sex nonconforming experiences. What has changed is that there is greater access to information and community, which makes it easier for people to come out. ↩︎
  2. “During the lifetime of the Review, the term trans has moved from being a quite narrow definition to being applied as an umbrella term to a broader spectrum of gender diversity. This clearly has implications for conceptualisations of detransition” (Cass et al., 2024, p.187). This claim is demonstrably false, as “trans” (and before that, “transgender”) has been used as an umbrella term for decades. This is shown in my own previous work as well as writing dating back to at least the 1980s by individuals such as Leslie Feinberg. ↩︎
  3. https://wrap.warwick.ac.uk/88285/ ↩︎
  4. For an excellent, more recent and more detailed analysis on this topic in the context of trans youth healthcare, see Magdalena Mikulak’s (2021) article “For whom is ignorance bliss? Ignorance, its functions and transformative potential in trans health“. ↩︎
  5. https://growinguptransgender.com/evidence/ ↩︎
  6. https://www.gold.ac.uk/educational-studies/staff/kennedy-natasha/ ↩︎
  7. https://www.gla.ac.uk/schools/socialpolitical/staff/harveyhumphrey/ ↩︎
  8. “Our stance, as gender-affirming practitioners, is that children should be helped to live as they are most comfortable. For a gender-nonconforming child, determining what is most comfortable is often a fluid process, and can modify over time. Therefore, in a gender affirmative model, gender identity and expression are enabled to unfold over time, as a child matures, acknowledging and allowing for fluidity and change” (Hidalgo et al., 2013). ↩︎
  9. “Since 2018, around 1.77% of young people who are referred to the gender care services at Sandyford have gone on to be prescribed puberty blockers”: https://www.thenational.scot/news/24262271.many-young-people-scotland-given-puberty-blockers/. ↩︎
  10. Although in practice, trans people are often also turned away from mental health services due to “trans broken arm syndrome“. ↩︎
  11. In my original speech, I inaccurately stated that the report was “500 pages long”. However, my point about requiring time to carefully consider its contents remains. ↩︎
  12. “The original published Terms of Reference (ToR) for the Cass Review’s assurance group explicitly excluded trans expertise, stating that it “deliberately does not contain subject matter experts or people with lived experience of gender services” [Report 1, version 1]. The current (updated) assurance group ToR is worded less clearly, yet still conveys exclusion of those with expertise or lived experience, as such individuals would naturally be expected to have an interest in the outcome of the review” (Horton, 2024: p.7) ↩︎
  13. One former gender clinician was involved in the research process: Tilly Langton, formely of England’s Gender Identity Development Service (GIDS). Langton’s recent activities include promoting conversion therapy materials in training for NHS psychiatrists and lobbying Kemi Badenoch about the UK government’s conversion therapy ban, alongside proponents of conversion practices. ↩︎
  14. Hilary Cass has contested this claim in reporting for the BBC. Her argument is that of the 103 studies analysed for the review, 60% were included in the synthesis of evidence. However, my argument here is specifically that the findings of these papers were broadly ignored in the writing of the report’s recommendations, while less robust material was instead prioritised. As Simon Whitten argues, “The majority of moderate certainty studies were included in the results section but then arbitrarily ignored in the conclusion entirely”. ↩︎
  15. I have removed a statement I made about randomised control trials from the transcript here as my point was unclear and therefore potentially misleading (as can happen when you do an unplanned speech on a complex topic!) Unlike the Cass Review team, I am keen to correct my errors. See the links in the above footnotes above for more detailed information on inclusion/exclusion criteria for the Cass Review. ↩︎
  16. See e.g. https://www.nps.org.au/news/is-paracetamol-effective-for-low-back-pain. ↩︎
  17. The landscape of evidence anti-psychotics is a complex one. There is “high-quality” evidence that anti-psychotic drugs work better than placebos in addressing various conditions, but the evidence for use of multiple drugs, reducing or increasing doses at particular junctures in treatment, or taking one drug rather than another in treating specific conditions is often of a similar (or lower) quality than the evidence for benefits of endocrine interventions assessed by the Cass Review (see e.g. https://www.sciencedirect.com/science/article/pii/S0890856716319992). ↩︎
  18. Specifically in the long-term, see e.g.: https://www.nationalelfservice.net/mental-health/adhd/adhd-medications-effective-safe/. ↩︎
  19. https://onlinelibrary.wiley.com/doi/10.1111/cen.14410 ↩︎
  20. At this point, somebody stuck their hand up in the audience. I responded: “Someone stuck their hand up and might give me a footnote on that! I totally approve of that. I might invite you up later because I like evidence and I’m obsessed with it. [person indicates they were just waving to their friend, crowd laughs] Oh that’s grand! There we go, we haven’t even had a footnote.” Well, here is the footnote. ↩︎
  21. p.24 of the Cass Review final report. The rationale for this within the report is that the figure is adapted from a 2018 paper published in Archives of Sexual Behaviour. However, as Trans Actual observe: “The number of referrals to GIDS is known until 2020/21 […] the last 3 years for which data is available, shows that the number of referrals has recently plateaued. Such data is inconvenient for a narrative that relies on an inexplicable explosion in need[.]” ↩︎
  22. https://transsafety.network/posts/gender-exploratory-nhs-training/ ↩︎
  23. A historical example of treatment that “tries to make the child comfortable with the sex he or she was born with” within a gender clinic context can be found here: https://www.npr.org/2008/05/07/90247842/two-families-grapple-with-sons-gender-preferences. ↩︎
  24. p.70, used to evidence the activities of GIDS’ research team at a WPATH conference. They could have instead cited the conference website. ↩︎
  25. A good summary of the channel can be found in this piece by What The Trans: “When citing a recording from the WPATH 2016 conference, Cass uses a YouTube channel called Thoughts on Things and Stuff. This appears to be the associated channel of a now-defunct blog largely focussed on criticising the Mormon Church. Why this was relevant to Cass is unclear, although titles of recent uploads at the time of the WPATH video include “Dr. Stephen Levine: 13 Untruths Behind Gender Affirmative Therapies for Kids” (Levine is an advisor to Genspect) and “Gays Against Groomers: stop the indoctrination and medicalization of children. 2023 Florida testimony.”, which perhaps provides a clue to how Hilary Cass ended up citing a channel with only 22.4K subscribers. It thus seems that, in addition to being advised by and networked with a variety of prominent anti-trans figures and organisations, Hilary Cass appears to be getting her professional news from homophobic and transphobic YouTube channels.”  ↩︎
  26. Anti-gay campaigners have long attempted to position LGBTIQ+ people as a danger to children. In recent years this tactic has seen a resurgence, through positioning trans and queer campaigners as “groomers”. GLAAD have described Gays Against Groomers as a group who intentionally use “ambiguous messaging about characterizing LGBTQ+ people as pedophiles falsely and maliciously with the absolutely clear intent of driving fear.” ↩︎
  27. pp.100-101 ↩︎
  28. https://transsafety.network/posts/bell-v-tavistock/ ↩︎
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What’s wrong with the Cass Review? A round-up of commentary and evidence

[last updated 10/05/24]

Wednesday 10 April 2024 saw the long-awaited publication of the final report of the Cass Review. This report was commissioned by NHS England, and provides a review of evidence plus recommendations regarding gender identity services for children and young people.

On publication, the Cass Review’s findings and recommendations were welcomed by the majority of UK media outlets, NHS England, the Editor-in-Chief of medical journal the BMJ, conversion therapy proponents such as SEGM, Sex Matters and Transgender Trend, plus spokespeople for the Conservative and Labour parties, who promised to ensure it will be “fully implemented”.

Conversely, the Review has been extensively criticised by trans community organisations, medical practitioners working in transgender healthcare, and scholars working in the fields of transgender medicine plus feminist and gender studies. They have highlighted issues including overt prejudice, pathologisation, poor and inconsistent use of evidence, non-evidenced claims, and the intentional exclusion of service users and trans healthcare experts from the Review process.

This post provides a round-up of links to existing commentary and evidence regarding problems with the Cass Review, plus quotes pulled from each. I hope it will be useful to support actions opposing the full implementation of the Review’s findings, such as:

  • letters to MPs, Parliamentary candidates, and NHS bodies;
  • voluntary sector and trade union advocacy;
  • protests and demonstrations.

I will seek to keep this post updated with new material.

Responses from healthcare professionals

British Association of Gender Identity Specialists (professional body for GIC clinicians)
Initial BAGIS statement on the Cass Review

“We are aware that this week’s release of the Cass review raises many questions and uncertainties for people accessing or wanting to access gender identity services, as well as for the staff working in those services. We also know that this is likely to be a source of significant distress and worry. On first glance, BAGIS Council are deeply troubled by some of the content of the Cass Review and the potential impact thereof. We will be considering this lengthy document carefully, and in detail, before offering a comprehensive response to its recommendations and before making any relevant observations regarding the process that has underpinned them.”

~

Professional Association for Transgender Health Aotearoa
Cass Review out of step with high-quality care provided in Aotearoa

“The final Cass Review did not include trans or non-binary experts […] in its decision-making, conclusions, or findings. Instead, a number of people involved in the review and the advisory group previously advocated for bans on gender affirming care in the United States, and have promoted non-affirming ‘gender exploratory therapy’, which is considered a conversion practice.”

~

The Australian Professional Association for Trans Health (plus others from Australia)
Cass Review out-of-line with medical consensus and lacks relevance in Australian context

“The Cass review recommendations are at odds with the current evidence base, expert consensus and the majority of clinical guidelines around the world.”

~

Therapists Against Conversion Therapy and Transphobia
Our interim response to the Cass Report

“TACTT is deeply concerned by the final report of the Cass Review, whose core underlying premise is effectively an eliminationist agenda, dressed up in the language of ‘reasonableness’ […] We urge clinicians to treat the Cass findings with extreme caution and not to assume that they represent best practice or that they have been arrived at after a full and impartial review of clinical data.”

~

CBC News
What Canadian doctors say about new U.K. review questioning puberty blockers for transgender youth

“While experts in the field say more studies should be done, Canadian doctors who spoke to CBC News disagree with the finding that there isn’t enough evidence puberty blockers can help. ‘There actually is a lot of evidence, just not in the form of randomized clinical trials,’ said Dr. Jake Donaldson, a family physician in Calgary who treats transgender patients, including prescribing puberty blockers and hormone therapy in some cases. ‘That would be kind of like saying for a pregnant woman, since we lacked randomized clinical trials for the care of people in pregnancy, we’re not going to provide care for you.… It’s completely unethical.'”

~

The National
Trans academics warn against ‘politicisation’ of Cass Review in Scotland

“[…] one experienced psychiatrist at a gender identity clinic in England – who did not wish to be identified – told the Sunday National that failure [to include those with lived or professional experience] had concerned many within the field. They said: “The terms of reference stated that the Cass Review ‘deliberately does not contain subject matter, experts or people with lived experience of gender services’ and Dr Cass herself was explicitly selected as a senior clinician ‘with no prior involvement … in this area’. ‘Essentially, ignorance of gender dysphoria medicine was framed as a virtue. I can think of no comparable medical review of a process where those with experience or expertise of that process were summarily dismissed’.”

Responses and publications from academic experts

Dr Cal Horton
The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children
(peer-reviewed article for the International Journal of Transgender Health)

“Inductive and deductive reflexive thematic analysis was applied to a collection of Cass Review publications related to trans children’s healthcare published between January 2020 and May 2023 […] Four concerns are presented and explored: (1) prejudice; (2) cisnormative bias; (3) pathologization; and (4) inconsistent standards of evidence. Each of these concerns impacts the Cass Review’s approach to trans children’s healthcare, with negative repercussions for trans children’s healthcare rights and well-being.”

Ten Dangerous Cass Review Recommendations

“Each of the recommendations summarised below is built on a foundation of prejudice, ignorance, cisnormativity and pathologisation of trans lives, running in direct opposition to the evidence base, and running in direct contravention of an NHS duty of care to children’s rights, children’s welfare, healthcare equality and healthcare ethics.”

Social transition, puberty blockers, and the Cass Review [added 08/05/24]

“The Cass Review has shown zero evidence of harms of social transition or puberty blockers. The only harm is this hypothesis that they change the trajectory and outcome, locking children into a trans lifetime. This hypothesis is based on the worst quality evidence I’ve ever seen. This is why trans healthcare researchers are feeling stress and dismay at UK media and politicians cheering on Cass’ evidence-based policy.”

~

Dr Natacha Kennedy
The Cass Review and Trans Exclusionism

“Despite the concern-laden language about “helping” and “supporting” trans children, it is my opinion that what Cass is attempting to establish is an all-enveloping ambient conversion therapy approach to trans children, removing their autonomy, freedom of expression, mental health, helpful support and healthcare. […] If imposed it will, in my view, result in the deaths and deterioration in mental health of many trans children.”

~

Dr Abs S Ashley
The Cass Review’s final report: The implications at the intersection of trans and neurodivergence

“Whilst the report cites adjacent NHS services using 0-25 models to justify a ‘continuity of care’ (224), designating trans persons as ‘vulnerable’ and confining them to child-oriented services indicates that more is at stake. These rhetorics contribute to the shoring up of state surveillance and intervention into the lives of legal adults who want to make choices the state disagrees with.”

~

Dr Chris Noone (and 200 colleagues) [added 26/04/24]
Irish academics say young trans people in Ireland deserve better than the recommendations of the Cass Review

“The Cass Review relies on six systematic reviews of different aspects of healthcare for young people accessing gender identity services. Systematic reviews are a way of compiling information from multiple studies that have looked at the same topic and come to an overall understanding of the results. There are very specific guidelines for how systematic reviews should be done but the Cass Review’s systematic reviews deviated from best practice in systematic review methodology in several ways […]”

~

Dr Gideon Meyerowitz-Katz [added 27/04/24]
Has there been an exponential increase in young people with gender dysphoria?

“One of the main arguments that the Cass review has made is that there has been a dramatic and hard-to-explain increase in the number of children who identify as transgender and attend UK clinics with gender dysphoria seeking help. In a number of places, the review describes this increase as “exponential”, and notes that it appears to have been accelerating in recent years. […] The authors say that this increase is far too big to be caused by social acceptance of trans people, and therefore there must be some form of pernicious influence such as social media, mental health problems, or some other issue causing kids to become trans at increasing rates. […] But if you look at the actual data in the reports that the review is discussing, not only is the increase not exponential, it’s not actually that surprising.”

What the review got right [added 08/05/24]

“I think it’s important to stick to the facts when critiquing a review such as the Cass report. […] I think the review made some serious mistakes in both science and interpretation, but they didn’t simply discard most of the evidence, or sneakily change their methodology to get rid of important research. The real story of the Cass review is much more complex than a single weakness that entirely discredits the work.”

Proving opponents of medical treatment for trans children wrong [added 08/05/24]

“Some of the main arguments AGAINST using hormones and medications for transgender children are contradicted by the Cass review. Barely anyone has noticed, because the review mentions this fact once in a single paragraph, and most of the data is relegated to Appendix 8. […] This should be a key point. A chapter of the review. “Common arguments against giving transgender children medications are wrong”. Instead, it’s a footnote. That raises all sorts of red flags. Why were these key findings shunted to an appendix and largely ignored?”

~

Dr Julia Serano [added 10/05/24]
The Cass Review, WPATH Files, and the Perpetual Debate over Gender-Affirming Care

“[The Cass Review] is just a review. In my previous essay, I cited numerous scientific reviews carried out by experts in the field which all came to a different conclusion than the Cass review: that gender-affirming care is beneficial and gender-disaffirming approaches harmful for trans and gender-diverse youth. If those reviews aren’t “authoritative” enough for you, then how about the American Academy of Pediatrics review, or the Endocrine Society review, or the WPATH Standards of Care, or any of the other health professional organizations who have come to similar conclusions.”

~

Dori Grijseels [added 27/04/24]
Biological and psychosocial evidence in the Cass Review: A critical commentary

“Several issues with the scientific substantiation are highlighted, calling into question the robustness of the evidence the Review bases its claims on, as such, calling into question whether the Review is able to provide sufficient evidence to substantiate its recommendations to deviate from the international standard of care for trans children and young people.”

~

Feminist Gender Equality Network
Letter from academics concerned about The Cass Review

“We suggest that the Cass Review contains unsound methodology, unacceptable bias, and unsupported conclusions. As academics and experts in the field, we regard The Cass Review as potentially harmful to trans children.”

~

Trans Learning Partnership
Initial Statement on the Cass Review

“Some of [the] recommendations follow entirely spurious narratives and draw unfounded conclusions. The whole report is positioned in a way which considers continuation of current medication access as harmful, but removal of the current medication access as a neutral or beneficial act, despite no evidence to support this. We are particularly concerned about the content discussing neurodiversity; social transition; and access to medications for children and young people. The report positions the fact that clinicians are unable to predict the future of children and young people’s gender expression as a critical failing of current practice. No service can or should aim to predict the future of children or young people’s lives and the idea that a clinician will know a young person better than they know themselves is in direct contradiction to the United Nations Convention on the Rights of the Child. The aim for clinicians should be to provide a safe, accessible and supportive service which provides individualised care to all children and young people it encounters.”

Responses from trans community organisations

Trans Safety Network
TSN Statement on Cass Review Final Report

“[…] we believe there to be systemic biases in the ways that the review prioritises speculative and hearsay evidence to advance its own recommendations while using highly stringent evidence standards to exclude empirical and observational data on actual patients. This adds to the concerns we have previously had about Cass excluding trans people from the research oversight board – that Cass was set up from the start to impose a particular perspective without input from the patient cohort affected by the outcome.”

Do no harm? The trouble with Cass’ therapy recommendations

“In the absence of effective treatments for dysphoria outside of transition, ‘alternatives’ rely primarily on impossibilising transition […] any therapeutic paradigm for trans and gender-variant young people must explicitly centre the reality and accessibility of transition and affirm all potential genders/embodiments, and should provide information on what pseudo-therapeutic manifestations of anti-trans rhetoric look like, both in clinical and community settings. Models that do not include this risk endorsing the influence of transphobic hostility on identity formation, for instance, or affirming rhetoric that assigned sex is ‘reality’ when this coheres with a given young person’s identity.”

Did the NHS ever stop funding conversion therapy? [added 08/05/24]

“Whether Hilary Cass wants conversion therapy to be institutionalised on the NHS again is immaterial: her recommendations have made space for it. Therapy is a caring profession, and despite the crueller parts of its history, good work happens under its banner – but so does violence. The NHS must set out a clear and actionable plan to keep conversion therapy out of its services, and investigate instances where it may have been allowed to take place. Anything else is complicity.”

Trans Safety Network statement on NICE evidence reviews on trans affirming care

“In June of 2023 it was disclosed to us by members of the Cass Review team that anti-trans author and commentator Dr Az Hakeem was part of “NHS England’s policy working group which commissioned the NICE evidence reviews undertaken in 2020”. Dr Az Hakeem has long been a partisan opponent of gender affirming medical treatments. While Hakeem disavows conversion therapy or trying to dissuade trans people from medical interventions, on his personal website he directs readers looking for specialist support for gender dysphoria to conversion therapy activist groups, such as Bayswater Support Group, and the anti-trans pseudoscientific lobby group SEGM. Hakeem is also a member of CAN-SG who have from their earliest webinars (link) promoted the idea that trans people should be dissuaded from transition and instead either change their minds, or undergo therapy to live with the discomfort of gender dysphoria without accepting their trans identity — in other words, that trans people should undergo conversion therapy.”

~

Trans Actual
The Cass Review is bad science and should not be taken seriously by policymakers

“The report […] strays far beyond its scope and competence in recommending a review of adult services and in suggesting that young people ought to stay under the care of children and young people’s services until the age of 25. The latter is based on highly questionable understandings of brain development which have been repeatedly debunked as an oversimplification of the constant changes in human neurology over the course of our lives. […] Underpinning this report is the idea that being trans is an undesirable outcome rather than a natural facet of human diversity. This is clear not only from the recommendations but also from the exclusion of trans researchers from the design of the review process and the links individual members of the research team have to anti-trans groups, which the Cass team were warned about.”

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The Cass Report – A Briefing

“The Report dismisses almost all evidence around existing protocols for treating trans young people, including lived experience, on the spurious grounds it does not meet unobtainable levels of proof. The team do not apply the same rigorous evidential tests to their own proposals. Indeed, if such evidential requirements were imposed consistently and equally across the NHS, it would mean that many routine treatments, including treatments for menopause, palliative care and mental health, would also have to cease.”

~

Gender Identity Research & Education Society
GIRES Statement following the publication of the Cass Report

“Of note, many other paediatric medications that are routinely used in paediatric care, do not and cannot have the level of evidence that Cass and NHS England demand: medicines for ADHD, for example, anti-psychotic medications, and many others have comparable if not lower levels of evidence.”

GIRES Chair Cat Burton:

“I was invited to consult with the Cass review. After three discussions it was obvious that the review had been written before we started. She totally discounted evidence from trans people from the basis of knowledge or lived experience.”

~

Mermaids [added 26/04/24]
Mermaids’ response to The Cass Review – In Depth

“Young people we have spoken to are concerned about what they have read, including the desire to understand “why” young people are trans, and to place what feel like “limits” on gender expression, further pathologising and medicalising their identities. We share these concerns. We are deeply frustrated with the lack of clarity throughout the report, which has enabled wilful misinterpretation and the spread of harmful misinformation. Clear and accessible language is vital, especially when services are operating in a context where there is significant hostility to and misconceptions about trans people, particularly in the media. “

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Trans Solidarity Alliance
Statement on the Cass Review

“In the world the Cass Review imagines a trans child will be seen quickly but not given the care they need. They will still wait for years if they want to access gender affirming healthcare. While they wait they will be expected to engage with therapy that risks becoming conversion practice. While they wait, they will go through a puberty they may find profoundly distressing. They will be treated for every other condition they have. They will be treated for conditions they develop as a consequence of denial of trans healthcare and living in a transphobic world. But they won’t get the care they need to feel comfortable in their own skin. This is a model of care that works for cis people who are upset by the idea of a trans child existing.”

~

Transgender Action Block
Our statement on the Cass Review

“The NHS has always been a violent, white supremacist, saneist, transphobic system; the Cass Report was never going to change that system, indeed it was designed to expand it. The NHS does not provide trans healthcare: it disciplines and punishes trans people, so we will transition in any way we can – with community-led care, private care, and overseas care. We will smuggle, borrow, share, and steal the medicine we need. We will take direct action to protect each other. We survive. We rebel. Fuck the NHS.”

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The Dyke Project
Today, we dropped a 30ft banner

“Politicians will continue to create moral panics to distract and divide us from their own failings. The Cass Review, instead of focusing on a lack of funding, long waiting lists and overstretched staff is ultimately calling to restrict trans healthcare. Enough is enough. Trans youth don’t need to be studied, managed or saved. They need the same opportunities and quality of care that their cis friends and family receive.”

Responses from human rights groups

Amnesty International and Liberty
Cass review on gender identity is being ‘weaponised’ by anti-trans groups

“This review is being weaponised by people who revel in spreading disinformation and myths about healthcare for trans young people. It’s concerning that sections of the media and many politicians continue to spread moral panic with no regard for the possible consequences for trans people and their families. The negative rhetoric by the Government about the dangers of so-called gender ideology, healthcare for young trans people, as well as the push against LGBT-inclusive sex and relationship education is harmful and extremely damaging.”

Critical and investigative journalism

Them
Advocates Say a Controversial Report on Healthcare for Trans Kids Is “Fundamentally Flawed”

“International medical organizations and transgender activists are roundly condemning a new U.K. report on gender-affirming care for minors, saying the report ignores years of research to propagate “harmful” misinformation.”

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Assigned Media
What’s in the Cass Report?

“The Report included many recommendations for treatment of youth presenting at gender clinics in England. Some of these were fairly technical, describing proposed relationships between NHS entities such as regional centers, centralized authorities, and local/tertiary providers. Other recommendations were broader […] The recommendations synthesize a view of medical transition as a bad outcome to be avoided, and a belief that gender dysphoria can be successfully treated non-medically, despite no non-medical interventions being evaluated in any of the series of systematic reviews[.]”

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Queer AF
Cass Review excluded 98% of gender-affirming hormone studies to reach its conclusion

“This week, when the Cass Review was released, news outlets rushed to cover the story, highlighting the report’s conclusions without taking time to consider whether the report could be flawed. In doing so, it amplified and solidified to the wider public the report’s key conclusions without balancing it against the evidence it excluded to reach them. […] Crucially, despite a four-year process, it still failed to find any smoking gun of widespread regret among trans folks who transition. It instead had to rely on a methodology that allowed it to exclude any data about how gender-affirming care helps trans people.”

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What The Trans?!
The Cass Review needs to be thrown out entirely. This is why.

“We contend that the Cass Review is not fit for purpose. We suggest that it was not merely knocked off course by a flawed methodology. We believe the Cass Report is a deliberate part of a political project aiming to reduce the availability of trans healthcare, possibly eventually in its entirety. It is imperative that we understand this and act on it.”

Trans Community in Scotland Protests Against NHS and Scottish Government Betrayal

“The trans and questioning children who are at the centre of this conversation are in community with one another, and they understand exactly what is happening to them. While we are focussed on the bigger picture, I was taken by their confidence and eloquence when speaking of their experiences. [A speaker shared] a story about speaking to a trans kid they knew through their work, who, speaking of their many friends who had died of suicide: “Yeah, you know how it is.” And we do. We are used to just how extreme what is currently happening to us in the UK is, and the real effects it has on us. We have been sounding the alarm for years, but we are now feeling the UK’s uniquely slow and bureaucratic oppression start to bite[.]”

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Yorkshire Bylines
The Cass review: trans care or trans scare?

“Children’s wellbeing is indeed at stake here, but that includes the wellbeing of children who are actually trans. Far from taking the matter out of politics, the review – and Rishi Sunak’s subsequent praise of it – has put it centre-stage. Some readers will remember the climate of homophobia that suffused the run-up to the 1997 general election, when the Conservative Party, desperate as it is now, brought out the “They’re coming for your children” rhetoric in a last-ditch effort to panic people into voting for it. This review – whose final report has been awaited for some time – feels like an attempt at the same thing.”

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Erin in the Morning
Opinion: England’s Anti-Trans Cass Review Is Politics Disguised As Science

“It is important to note that the Cass Review contains very little new data and evidence. Any statements it makes are based on the same level of evidence that every major medical organization in the United States, along with some of the largest mental health societies in the world and professional associations of transgender health, have determined to support transgender care. If its claims differ from those institutions, it’s because reviewers made choices to view the evidence around transgender care negatively.”

Dr Cass met with DeSantis Pick Over Trans Ban: Her Review Now Targets England Trans Care

“The Cass Review seems to have emulated the Florida Review, which employed a similar method to justify bans on trans care in the state—a process criticized as politically motivated by the Human Rights Campaign. Notably, Hilary Cass met with Patrick Hunter, a member of the anti-trans Catholic Medical Association who played a significant role in the development of the Florida Review and Standards of Care under Republican Governor Ron DeSantis. Patrick Hunter was chosen specifically by the governor, who has exhibited fierce opposition towards LGBTQ+ and especially transgender people, and then immediately got to work on targeting transgender care. The Florida review was purportedly designed and manipulated with the intention of having “care effectively banned” from the outset, as revealed by court documents. The Florida Review was slammed by Yale Researchers as “not a serious scientific analysis, but rather, a document crafted to serve a political agenda,” and much of their full critique is applicable to the Cass Review as well.”

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Trans Writes
The 32 things The Cass Review recommends and why they are concerning

“The 32 recommendations, informed by the highly conservative evidence base, look to impose further restrictions and control on trans lives — and not just the lives of trans youth with the scope of these recommendations including 25 year olds. 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.”

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The Autonomy
Between Reproductive Past and Trans Future

“The overall recommendation is to force patients to wait through psychological busywork and relevant-sounding delays, implementing a largely-arbitrary set of hoops to jump through with the hopes the patient just gives up. Focus on the patient’s anxiety, focus on their autism, focus on any other issue except their gender and their desire for a sex change[.]”

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404 Media
Review Used By UK to Limit Gender Affirming Care Uses Images of AI-Generated Kids

“Earlier this month, WIRED noted that generative AI has a track record of representing queer and trans people as a collage of stereotypes. It is not clear why the Cass team used AI-generated images in this report, which, again, has been used as evidence by the NHS to stop providing gender-affirming care to trans kids.”

Social media

Chamber Voice (published by policy institute Curia) [added 24/04/24]
How politically unbiased is Cass?

“Questions have been raised about the neutrality & evidence basis for the controversial #CassReview. The report’s author Hilary Cass has been asked to provide answers why she is meeting with Women’s Declaration in the House of Lords this week.”

Context note: under their old name of Women’s Human Rights Campaign, the organisation Women’s Declaration International have openly called for the “elimination” of trans people. More information on the meeting can be found here.

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Ethel Weapon
#Cassflaws threads on Bluesky

“§6.18 presents us with the idea that toy choice is influenced by hormones. To accept this report is to accept that estrogen, for example, has a biological effect that causes a preference for play with toy cooking pans over toy trucks. In §6.23 we are directed to the work of Melissa Hines in support of this hypothesis. Hines was one of the two authors of the “vervet monkey” study that claimed to show such toy preferences in monkeys. A study that implies something about estrogen makes monkeys want to play with cooking pans.”

“Here is Cass citing “Thoughts On Things And Stuff”. This is a YouTuber whose channel includes a host of anti-trans video material, including material from notorious anti-trans figures, including ‘”‘Gays Against Groomers’.”

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TransSafetyNow

“It has been drawn to my attention that [a booklet produced based on research cited by the Cass Review] was funded by SEGM’s William Malone & anti Trans lobby group Transgender Trend.”

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猫好きな人

“In 2021, Trilby “Tilly” Langton, the sole gender affirming care “expert” involved in the Cass systematic reviews, went to lobby Kemi Badenoch about the conversion therapy ban. With a featured speaker at the 2024 CAN-SG conversion therapy conference.”

~

Simon Whitten
Did the Cass Review disregard the evidence of all but 2 of 103 studies on puberty blockers & hormones to reach it’s conclusions? Yes and no.

“The review found 5 studies of moderate certainty relevant to psychological health. All 5 supported the conclusion that treatment of trans teens with CSH [cross-sex hormones] improved psychological health. There were no findings of worsening psychological health. What conclusions would you draw from this? Our intrepid authors draw no conclusions from this whatsoever, instead declaring the evidence for every outcome for which there was no high certainty study “inconclusive.” Similar is true for other outcomes and for puberty blockers. This is the sense in which the Cass Review absolutely did ignore almost all evidence on the efficacy & safety of PBs [puberty blockers] and CSH. The majority of moderate certainty studies were included in the results section but then arbitrarily ignored in the conclusion entirely.”

Dr Cass Responds

The Kite Trust
Q&A with Dr Hilary Cass

“The Cass Review Report does not conclude that puberty suppressing hormones are an unsafe treatment. The report supports a research study being implemented to allow pre-pubertal children to have a pathway to accessing this treatment in a timely way and with suitable follow up and data collection, to provide the highest quality of evidence for the ongoing use of puberty suppressing hormones as a treatment for gender dysphoria. In the data the Cass Review examined, the most common age that trans young people were being initially prescribed puberty suppressing hormones was 15. Dr. Cass’s view is that this is too late to have the intended benefits of supressing [sic] the effects of puberty and was caused by the previous NHS policy of requiring a trans young person to be on puberty suppressing hormones for a year before accessing gender affirming hormones. The Cass Review Report recommends that a different approach is needed, with puberty suppressing hormones and gender affirming hormones being available to young people at different ages and developmental stages alongside a wider range of gender affirming healthcare based on individual need.”

Some final thoughts: recommendations such as this from the Q&A are not clearly reflected in the content of the report or the later Q&A published on the Cass Review website. In a blog post accompanying that Q&A, Dr Cass complains about “some of the assertions being made on social media, and occasionally on mainstream broadcast media, which misrepresent the report and its findings, whether wilfully or otherwise“.

In my expert opinion, the critiques linked to in this blog post have yet to be properly addressed by the Cass Review team, let alone any of the politicians or healthcare service directors promising the implementation of the Review’s findings.

Regardless of whatever Dr Cass’ intention may or may not have been, the Review process itself intentionally and explicitly excluded any oversight from service users and trans healthcare experts, and involved collaboration with proponents of conversion practices. The final report relies on poor and inconsistent use of evidence, and makes recommendations that put young trans people in danger.

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RCGP host conversion therapy conference in London – protest 23 March

On Saturday 23 March the Clinical Advisory Network on Sex and Gender (CAN-SG) are hosting at conference at 30 Euston Square, the headquarters of the Royal College of General Practitioners. CAN-SG are described by Trans Safety Network as “an organisation composed mainly of activists involved in the pseudoscience network SEGM, and the anti-trans conversion therapy campaigning body Genspect“.

A noise demonstration will be held outside the conference venue from 10am on 23 March, hosted by Transgender Action Block, Lesbians and Gays Support The Migrants, and The Dyke Project.

Protest poster, which reads as follows. Noise demo against Royal College of GPs conversion therapy conference. 30 Euston Square, March 23rd, 10am, 2024. Get loud, get angry against institutionalised abuse. No parasan. Full youth autonomy now. No cops, no SWP, no Tories.



According to the Memorandum of Understanding on Conversion Therapy, an agreement signed by 40 leading professional bodies and healthcare providers, conversion therapy “is an umbrella term for a therapeutic approach, or any model or individual viewpoint that demonstrates an assumption that any sexual orientation or gender identity is inherently preferable to any other, and which attempts to bring about a change of sexual orientation or gender identity, or seeks to suppress an individual’s expression of sexual orientation or gender identity on that basis”. Conversion therapy has been described as a form of torture in academic work and by UN experts.

The CAN-SG event speaker lineup is a who’s who of conversion therapy proponents and anti-trans activists, including:

  • Stelley O’Malley, founder and director of Genspect, who has described seeking to suppress the gender identity of teenagers in her therapeutic work, adding: “I don’t think you should have empathy or sympathy” for young trans girls.
  • Michael Biggs, an anti-trans campaigner linked to a prolific troll account on Twitter.
  • Richard Byng, a member of anti-trans pseudoscience network SEGM.
  • Rachel Cashman, a campaigner against trans inclusion in schools, and supporter of Women’s Declaration International (WDI). Under their former name of Women’s Human Rights Campaign, WDI have openly called for the “elimination […] of the practice of transgenderism”.
  • Az Hakeem, a member of Genspect and an active opponent of a proposed legal ban on conversion therapy. Hakeem was reported for conversion therapy to the GMC by a former patient.
  • Anne Hutchinson, who has promoted materials by Genspect in training for South London and Maudsley NHS Mental Health Trust.
  • Riittakerttu Kaltiala, a Finnish clinician and opponent of affirmative care who contributed evidence for Florida’s ban on medical transition for young trans people. I have not found any evidence that Kaltiala opposed Finland’s policy of forced sterilisation as a condition of legal recognition for trans people, which was repealed only last year, but am willing to be corrected on this. According to a recent academic biography, Kaltiala sits on the advisor board of the Cass Review.

The Royal College of General Practitioners (RCGP) are signatories of the Memorandum of Understanding on Conversion Therapy. Signatories agree that conversion therapy is “unethical and potentially harmful”, and commit to ending this practice in the UK.

Following complaints from LGBTIQ+ groups and their own members, the Royal College of General Practitioners (RCGP) released a statement saying that the conversion therapy conference would go ahead. In the statement, they argue that their headquarters building, 30 Euston Square, is “an event space run by an independent events company”. However, the statement opens by saying that the RCGP has “reached the decision that the Clinical Advisory Network on Sex and Gender (CAN-SG) conference can go ahead”, and later adds that “the College would be at risk of being faced with a claim for breaching the Equality Act if we acted otherwise”. This implies that the RCGP do, in fact, have control over their own building, and have taken the active decision not to oppose the conference.

Legal threats are increasingly common from anti-trans campaigners, who argue that cancelling contracts or events constitutes an attack on their “gender critical” views as “protected beliefs”. The CAN-SG conference has been widely reported as a gender critical event, and indeed several of the speakers appear to describe themselves as “gender critical”. However, the issue with the event is not the beliefs of the speakers or organisers in and of themselves. It is that they are actively promoting disinformation and harmful practices.

The RCGP’s position is therefore one of gross cowardice, and demonstrates that they are not actually committed to preventing harm against trans people in healthcare settings. It costs the RCGP very little to sign a document claiming that they oppose conversion therapy, or condemn the UK government for failing to introduce a legal ban. However, now that the fight against conversion therapy has come to their door, they are not prepared to act.

It is within the power the RCGP to ensure that the CAN-SG conversion therapy is cancelled. They have chosen not to do this. It is within the power of the RCGP to oppose CAN-SG in court, if it came to that. They have chosen not to.

This reflects the same failures we have seen from bodies including NHS England and the Cass Review. I am often asked why trans people do not trust doctors. This is why. We are failed by medical professions over and over again.

Change happens not because powerful organisations allow it, but because ordinary people fight for it. A true commitment to ending conversion therapy can be seen not in the actions of RCGP, but in the work of groups like Transgender Action Block, Lesbians and Gays Support The Migrants, and The Dyke Project. I am also hugely grateful to grassroots organisations such as Trans Safety Network, Health Liberation Now, and Gender Analysis for gathering a lot of the information I collated in this post.

That power also potentially lies with you. Trans support groups and harm reduction networks for people self-medicating can be found across the UK, and will always benefit from your support. And you can complain to the RCGP here.

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13 days to defend trans and queer kids

On 12 March 2024, the UK Department of Education consultation on draft guidance on “gender questioning children” for schools and colleges will close. Until that date, we have our best possible chance to fight for the safety and wellbeing of young people.

Last month I wrote a long blog post and zine about this draft guidance: New Year’s Resolution: Smash the New Section 28. I argued that the guidance resembles the notorious anti-gay law Section 28, in that it aims to both directly oppress LGBTIQ+ young people, and create an atmosphere of fear and uncertainty around supporting them. This is to be done by reinforcing a strict sex binary. The guidance directly targets young trans people, but also threatens to enforce sexist and homophobic standards on all students, e.g. through stating that school uniforms should be allocated on the basis of “biological sex”.

I also argued that there are important reasons for hope, and many routes to resistance. One possible option is to take part in the consultation itself, but there are other approaches too, including noncompliance and resistance in schools, contacting politicians and unions to raise the alarm, supporting trans youth groups, and creative forms of protest.

Since I wrote Smash the New Section 28, the situation for young trans people has continued to deteriorate. In the UK, the Government has very quietly introduced a second consultation on proposals to segregate trans college students who are on trips or who would otherwise be sharing accommodation with other students. In the US, the murder of trans student Nex Benedict in a school bathroom shows just how dangerous the UK proposals would be in practice. I have updated my original post to reflect both of these events. Moreover, it’s emerged that the Royal College of GPs are hosting a conference for conversion therapy advocates in London, and the British public are more openly prejudiced towards trans people than they were just five years ago.

However, it’s also been really heartening to see how many people have read the blog post and shared the zine over the last month. I have particularly appreciated the support from the amazing independent Leeds book shop The Bookish Type, who have been giving away loads of free copies of the zine. I have heard from parents and bureaucrats who say they are using what I have written to argue for independent guidance that actually supports trans and gender non-conforming young people in schools and college.

Importantly, my writing is just one piece among many. Important critiques and consultation guides have been published by people and groups including The Diversity Trust, Just Like Us, Nancy Kelley, Gendered Intelligence, LGBT Foundation, Mermaids, Stonewall, and the Trans Learning Partnership. If you’re aware of any good writing or resources, please share in the comments and I will add it to this post.

You and the people you know have the resources to take action against the new Section 28. If the guidance is implemented, this will not be our only opportunity to fight back, but it is the best opportunity. Think about what you can do before 12 March: whether it’s writing to school governors or an MP, agitating in your workplace or union, or sharing information with others.

As ever, we can never win freedom alone, but have so much power when we act with others.

Photograph of a women holding a zine titled Smash The New Section 28. The woman is white and has shoulder-length brown hair, and is wearing glasses and a grey t-shirt. She stands in front of a large book shelf.
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Let’s respond to the NHS consultation together!

A couple of days ago I joined Katy Montgomerie’s livestream to work through the current NHS England consultation on child and adolescent gender services. We discussed the background to the consultation, what the questions mean, and what some of the major issues are.

You can take part in the consultation here. It is open until 4th December 2022. Filling it in is a bit of an intense experience, but if you fancy some friendly company and catty cameos, I hope our video will help.

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The GRA, LGBT Survey, Action Plan and conversion therapy ban – what just happened?

On Tuesday, the UK Government (finally!) launched a long-awaited consultation on reforms to the Gender Recognition Act 2004 (GRA). This has been timed to coincide with several other events, including the publication of initial data from the Government Equality Office LGBT Survey, the launch of the Government’s new LGBT “Action Plan”, and the formal launch of the Memorandum of Understanding on Conversion Therapy.

While it makes sense – politically speaking – for all of these things to happen at once, it can be pretty confusing. The sheer amount of information to process alone is monumental. Part of my job is to engage with these events, and since yesterday morning my head has been spinning! So in this post I aim to briefly summarise what has happened, why it happened, and what this might mean for the future – especially with regards to trans rights.


GRA Consultation

Planned reforms to the GRA was announced in the wake of the 2017. The Government promised a consultation, which has taken a year to materialise.

Nevertheless, it’s now open and anyone can respond to it. The consultation outlines a number of issues that civil servants have identified with the GRA as it stands, and asks for your views on these.

You can read about and respond to the GRA consultation here.

There are a couple of issues with the GRA which trans rights advocates have highlighted as notably absent from the consulation, which you may wish to invite the Government to also address. These are:

  • The lack of provision for gender recognition for trans people under the age of 18.
  • No mention of the Gender Recognition Register, which currently lists all people who have successfully applied for gender recognition. This may prove a danger to trans people if a more authoritarian government were to come to power, as in the US.

In the past year there has been a moral panic in the UK media in response to proposals for GRA reform. You can find out more about this (and my thoughts on why the consultation is happening now) in my earlier post on the topic.


LGBT Survey

In 2017 the Government Equality Office launched the National LGBT Survey. This was the largest survey of LGBT (in)equalities ever conducted – not just in the UK, but the world. A total of 108,100 valid responses were recieved, of whom approximately 14,000 were trans (which also makes it the largest ever survey of trans people in the UK by an astonishing margin). Credit for this is due to the civil servants who quietly pushed through its implementation at a time of political turmoil and reshuffles in the wake of the general election, as well as the LGBTQIA+ organisations who promoted it extensively.

An initial research summary report was published on Tuesday. This provides a basic account of the research findings. The full research report was released late on Wednesday. This huge document provides a far deeper and more extensive look at the survey results. However, there is such an enormous amount of data available that researchers will probably be analysing the findings for years to come.

The timing of these publications is not a coincidence. The research included questions about gender recognition; the findings demonstrated a strong demand for reform from the trans population, with negligible opposition to proposals from cis respondents. The Government will therefore use this to back their attempt to reform the GRA.

You can read the reports of the LGBT Survey here (along with various data annexes).

You can read my initial reflections on the summary report in this Twitter thread.


LGBT Action Plan

In response to the findings of the LGBT Survey, the UK Government has produced a 75-point Action Plan. This describes the actions they propose to take to promote LGBT equality, which include drafting new laws, producing new policy and guidance, and ringfencing money from the Government Equality Office budget for carrying out equalities work.

It’s very easy to be cynical about “action plans” such as these, but they can actually have a real impact. For example, the Coalition Government’s 2011 Transgender Action Plan was widely regarded as useless by trans activists in following years, but (as I show in my research) its requirement for the implementation of new gender identity service protocols by April 2013 helped bring about important improvements in NHS England gender clinics. This included an end to the requirement for a local mental health assessment prior to a gender clinic referral, which reduced the number of waiting lists that transitioning patients have to endure.

The legislative centrepieces of the Action Plan are the proposed reform of the Gender Recognition Act, and a proposed ban on conversion therapy. Both potentially represent important steps forward for the law, but would also require relatively minimal action from the Government to tackle pressing issues highlighted elsewhere in the survey data (such as the enormous economic inequality experienced by LGBTQIA+ people). There are, of course, matters which weren’t asked about in the survey either, such as the UK’s treatment of LGBTQIA+ migrants and asylum seekers.

Therefore, in addition to holding the Government to account for implementing the LGBT Action Plan, we need to continue campaigning on matters such as austerity, immigration rights and the provision of public services.

You can read the LGBT Action Plan here.


Memorandum of Understanding on Conversion Therapy

On Wednesday afternoon I attended the formal launch of an effective ban on conversion or reparative therapy that has been agreed upon by the UK’s major professional bodies for therapists, counsellors, psychologists and psychiatrists. This is a really big deal because it represents an attempt to stamp out practices that aim to “cure” or “convert” a person’s gender identity or sexual orientation.

The Memorandum of Understanding was originally agreed upon in 2016. This document only addressed LGB conversion therapy. but (following a series of careful meetings and difficult negotiations) an updated version was published in 2017, which explicitly addressed conversion therapy targeting people on the grounds of gender identity. This was effectively a “soft launch”, ensuring that the document was made available to those who needed it.

Today “officially” launched the document in the House of Commons, with numerous MPs and representatives of religious and therapeutic organisations present. The idea was to promote the Memorandum of Understanding more actively, and draw attention to the issue of conversion therapy among all of these groups.

I was not very much involved in the drafting of the Memorandum of Understanding, but did attend one of the early meetings that discussed how it might be extended to ensure asexual and trans inclusion. At this meeting we struggled with the lack of formal evidence that trans people in particular were undergoing conversion therapy, although I supported others in arguing that the prevalence of deeply concerning anecdotal accounts alone necessitated action.

By coincidence(?) today’s formal launch event coincided with yesterday’s publication of the first ever statistics on LGBTQIA+ conversion therapy in the UK, as part of the LGBT Survey summary report. These figures are stark: 5% of respondents reported being offered conversion therapy, and 2% underwent it. That might sound like a small figure, but given the enormous response to the survey, what it means is that thousands of vulnerable LGBTQIA+ people have experienced these damaging practices in the UK. Worryingly, the survey also shows that young people continue to experience conversion therapy, and that the situation is more severe for trans people. Around 10% of trans respondents reported having been offered conversion therapy, and 4% stated that the had been subject to it.

Dr Igi/Lyndsey Moon from the Coalition Against Conversion Therapy, who played a key role in ensuring that the document was updated to include trans people, spoke passionately at the event. In addition to talking through some of the above figures, they also argued that simply attempting to “ban” conversion therapy may not result in the change we need to see. What needs to happen now is the long, hard work of cultural change – both within religious organisations, and within healthcare services.

You can read the Memorandum of Understanding on Conversion Therapy here.
Edit: I updated this post on the morning of Thursday 5th July to include a link to the full research report, which is now also available.

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Ethical guidance on studying trans health, for researchers and ethics boards

I recently co-authored an article on research ethics for the journal Transgender Health. It’s based on an extensive review of literature on the topic, and written by an international team of scholars and health practitioners with extensive experience of conducting research in this field.

Transgender Health is an open access journal, so the article is freely available for anyone to read and share.

I’ve copied the abstract out below: please click on the title for full access.


Guidance and Ethical Considerations for Undertaking Transgender Health Research and Institutional Review Boards Adjudicating this Research

The purpose of this review is to create a set of provisional criteria for Institutional Review Boards (IRBs) to refer to when assessing the ethical orientation of transgender health research proposals. We began by searching for literature on this topic using databases and the reference lists of key articles, resulting in a preliminary set of criteria. We then collaborated to develop the following nine guidelines:

(1) Whenever possible, research should be grounded, from inception to dissemination, in a meaningful collaboration with community stakeholders;

(2) language and framing of transgender health research should be non-stigmatizing;

(3) research should be disseminated back to the community;

(4) the diversity of the transgender and gender diverse (TGGD) community should be accurately reflected and sensitively reflected;

(5) informed consent must be meaningful, without coercion or undue influence;

(6) the protection of participant confidentiality should be paramount;

(7) alternative consent procedures should be considered for TGGD minors;

(8) research should align with current professional standards that refute conversion, reorientation, or reparative therapy; and

(9) IRBs should guard against the temptation to avoid, limit, or delay research on this subject.

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Some tips on opposing Kenneth Zucker’s new article on trans children

This morning it came to my attention that notorious child psychologist Kenneth Zucker has co-written a chapter on trans issues for the new (6th) edition of Rutter’s Child and Adolescent Psychiatry. The chapter, entitled “Gender dysphoria and paraphilic sexual disorders” effectively draws upon flawed and outdated research to promote reparative therapy for trans children. You can read most of it via Google Books here.

Cover of Rutter's Child and Adolescent Psychiatry

Abusing children – for science!

This is a big deal because Zucker draws upon harmful theories (including Ray Blanchard’s deeply reductive typology of transsexualism) to promote the idea that issues faced by gender variant children are due to a problem with the child, rather than societal gender norms. He therefore promotes a form of treatment that (to quote his new article) encourages parents to “set limits with regard to cross-gender behaviour, and encourage same-sex peer relations and gender-typical activities” in an attempt to cure them of difference. This is the kind of treatment that leads children to internalise the idea that non-normative gendered expression is shameful or wrong.

Rutter’s Child and Adolescent Psychiatry, meanwhile, is a widely-used textbook and can be found in university libraries and on reading lists in many countries.

I’m not sure what the best way is to stop this article from influencing practice. However, some ideas could include:

  • Write to professional organisations and ask them to explicitly oppose reparative therapy for trans youth
  • Write to University libraries and courses, asking them to consider sticking with the 5th edition of Rutter’s
  • Write to University departments and ask them to teach critical texts alongside the 6th edition of Rutter’s, and/or avoid putting the new edition on reading lists
  • Borrow the book from a local library if it becomes available, and write critical comments in the margins
  • Write to the book’s editors and/or publisher and question why Zucker has been given a platform for his outdated ideas
  • Comment on this post and/or join this new Facebook page to discuss possible ways forward.

The new edition isn’t yet widely available in libraries, so now is a good time to act.

If you’re writing letters or raising awareness of this as an issue, here is some useful information on opposing the article:

  • Zucker’s approach to treatment can seriously harm children
  • Zucker’s Gender Identity Service at the Toronto-based Centre for Addiction and Mental Health was recently suspended pending investigation in the wake of a large number of complaints – his approach to treatment is now also arguably illegal in the province of Ontario
  • Zucker’s new article represents poor academic practice. He cites himself 17 times, relies upon papers at least 20 years out-of-date to make many of his arguments, and also draws strong inferences from statistically insignificant quantitative findings
  • Zucker’s considerable academic position is based in part upon a small “invisible college” of academics who regularly peer-review and cite one another, thereby gaining many publications with a high profile whilst avoiding external criticism
  • There is a considerable evidence-based case to be made against Blanchard’s work. See for instance “The Case Against Autogynephilia“, a peer reviewed article by Julia Serano.

Thanks and respect to Peter Le C for raising awareness of this issue, and to oatc for suggested edits.