On the evening of Tuesday 15th April 2025, I was widely perceived to be a British lesbian, both legally and socially. By 11am the following day, that was no longer the case, following a ruling by the UK’s Supreme Court.
I was not actually in the UK for this momentous occasion. I was instead in the Swiss city of Lausanne, for a workshop on standards of evidence in sex and gender policy. I was there to consider the very questions the UK’s highest court, in their supreme ignorance, had effectively dismissed. Their ruling determined that the term “sex” in the Equality Act referred to “biological sex”, which in turn should be understood as “the sex of a person at birth”. But what do we actually need to know about when we make policy around sex and gender, and what is the role of evidence in this?
The Tuesday evening found me hanging out in a second-rate Thai restaurant with Professor Sarah Lamble, an esteemed criminologist and fellow dyke. Lamble and I spent some time talking about how conspiracy theories around “disappearing lesbians” highlighted the strange ironies inherent in British anti-trans discourse. The anti-trans movement has been extremely successful in raising “reasonable concerns” around supposed problems that are completely ungrounded in reality, to the point where that reality itself begins to warp.
Mainstream political discourse in the UK increasingly reflects anti-trans claims that lesbians are somehow threatened by trans people, or are even being transed en-masse in gender clinics and youth groups. The true biological attraction between two adult human females is disrupted. Young people are tempted away from lesbianism with promises of luxurious facial hair and male privilege; meanwhile, horrifically manly and/or confusingly attractive trans dykes are introduced to the dating pool.
If these claims were true, we might expect to see some kind of reduction in the number of homosexual females. Instead, the evidence we have indicates quite the opposite. Surveys such as the Annual Population Study show a rising number of lesbians over recent years, part of a wider increase of 1.2 million in the recorded lesbian, gay, and bisexual (LGB) population of the UK. This is driven especially by young people coming out, with over 10% of people aged 16-24 identifying as LGB as of 2023.
But what about the lived reality of queer womanhood? Well, there’s great news here too: we are living in a truly historic time for sapphic culture in the UK. Proudly out lesbian and bisexual women can be found across the pop charts, on TV, and across social media. Queer bookshops are on the rise. Pop-up butch bars and new queer cafes can be found in major cities and small towns. And, excitingly, even the much-maligned lesbian bar is making a comeback, with three permanent venues and numerous occasional nights now running in London alone. It’s all got so out of hand that in 2024 the Queer Brewing company sold a juicy pale ale named Dyke Renaissance, which conveniently listed an educational series of cultural milestones on the can.
If trans people are trying to disappear lesbians, we’re doing a really bad job of it.
Meanwhile, queer cis women tend to be pretty supportive of trans people. In fact they’re one of the single most supportive demographics in the UK – which is presumably why the Equality and Human Rights Commission is, right now, attempting to ban trans dykes such as myself from associating with any more than 25 biological lesbians at any one time.
On evidence
As lesbian conspiracy theories show, the very concept of evidence has had a bit of a hard time over the past decade.
In the UK, this was perhaps best encapsulated in 2016 by the Conservative politician Michael Gove. While campaigning for Brexit, he declared that the British people “have had enough of experts”. Gove’s claim is echoed in a growing anti-intellectualism across the globe. From the mass purge of universities in Türkiye, to the post-truth bizarro world of Donald Trump, to Israel’s scholasticide in Gaza, this trend manifests in blunt and brutal ways. Anti-expert authoritarianism doesn’t care about your facts or your feelings.
However, attacks on evidence can also be more subtle. Gove’s comments are widely quoted, but it’s less well-known that he singled out a particular kind of expert for criticism: “people from organisations with acronyms saying that they know what is best and getting it consistently wrong”. While this was gloriously vague in a way that allowed the listener to project all kinds of things onto Gove’s words, in context it was nevertheless evocative of the kind of group that tends to advocate for social justice. LGBTQQIAAP groups, perhaps.
From academic thinktanks, to charities, to campaigning organisations, the implicit problem was any kind of challenge to conservative common sense. The UK’s political mainstream has since doubled-down on this approach. In the run up to the 2024 general election, Tory home secretary Suella Braverman criticised “experts and elites”, while the secretary of state for science, innovation and technology, Michelle Donelan, promised to “kick woke ideology out of science”.
One of Donelan’s targets was the “denial of biology” in research by feminists, social scientists… and biologists. The problem here is that supposedly common sense notions of sex and gender, which assume clean and tidy biological divisions between male and female, collide violently with the beautiful messy reality of the material world. At this point in history, it is well-established that sexual diversity exists throughout nature, that men are not biologically superior to women, that social advantage is not conferred or denied by chromosomes, and that queer, trans, and intersex people exist in the world. The evidence for this is gloriously multifaceted. We find it in laboratories, in systematic reviews, in surveys and questionnaires, in the way that men shout abuse at us in the streets, in how our sexed bodies shift and change under hormonal influence, in the way we feel when we finally have a language that describes our experiences.
Michelle Donelan decided to tackle the thorny problems of feminist science, intersex bodies, and trans existence by commissioning a research project by Alice Sullivan, a supposed sociologist who doesn’t care one jot for any of the evidence outlined above. Published in March 2025, the Sullivan Review insisted that data collection relating to sex and gender should rely on a very narrow definition of biological sex: one that ignores trans and intersex women’s real lives, bodies, and experiences of misogyny, while promoting a sexist model of essentialised womanhood. Her findings were echoed in those of the Supreme Court judges a month later, whose pronouncements on biological sex were made without any reference to relevant social, scientific, or philosophical research on how this might actually be understood or defined in practice.
To position this as a wholly new trend would, of course, would be inaccurate. Western jurisdictions have long used and abused pseudoscience to oppress minoritised groups, especially in colonial contexts. This can be seen for example in the British state’s shameful embrace of “race science” and eugenics in the 19th and 20th centuries. What we are now witnessing is an example of the imperial boomerang, in which the logics of colonialism are turned inwards, resulting in increasingly fascist domestic politics.
But did you have a nice time in Switzerland, Ruth?
On that fateful week in April, I joined a group of feminist, trans, and lesbian researchers and activists for the workshop at the University of Lausanne. In the face of increasingly ill-informed policymaking across multiple contexts, it provided us a space to think together about the lessons we might learn collectively from our very different work on healthcare, sports, and prisons.
One overarching theme was the importance of evidence in understanding human experience, in terms of rigorous data collection, careful analysis – and accounting for the lived reality of actual people’s actual lives. A powerful account of the latter point was provided by Dinah Bons, a veteran campaigner for HIV prevention. She pointed out that if a sex worker repeatedly attends a community clinic for her STI tests, this provides evidence that the clinic feels safe enough for her to return regularly, which is far from a given. Such matters are often highly evident to service users and providers on the ground, without any need for a survey or interview.
Another key theme at the workshop was the extent to which various principles of evidence are increasingly abused by politicians, journalists, and institutions.
The concept of evidence has not been rejected wholescale by sexist, transphobic, and lesbophobic policymakers. Rather, “evidence” is increasingly a buzzword to justify particular approaches or points of view, rather than something grounded in a commitment to scholarly standards or an acknowledgement of lived experience. At the workshop, we explored how flawed notions of evidence have been used to support misleading statements or outright lies about human bodies or human experiences. We heard about the use and abuse of evidence in justifying invasive sex-testing for woman athletes, misrepresenting research on young people’s ability to engage in informed decision-making, and defending conversion practices. Notably, while most of these abuses arose from a specifically transphobic politics, they have far wider consequences: especially for women, intersex, and queer people, but also for scientific processes, community consultations, and informed advocacy more broadly.
You can see an example of this in the Cass Review. Through successfully performing the aesthetics of acceptable expertise and science to the satisfaction of the British public, the Review has become what one workshop participant described as a black box. By this they meant that it has become an abstracted justification for policy and practice, handily replacing any ongoing discussion of evidence regarding young trans people’s health and wellbeing. You don’t need to know what the Cass Review actually says or how rigorous it actually is, only that it exists. Well-documented criticisms of the review from healthcare practitioners, academic experts, trans community groups, and (most importantly) young trans people themselves are been rendered irrelevant. The Cass Review is the evidence, and no other systematic review, original research, or personal testimony can henceforth count against it. Not, at least, until 2031 at the earliest: the official end-date of a single £10 million study, based on the Cass recommendations and featuring precisely zero trans researchers.
The British establishment is now attempting to repeat this trick with the Sullivan Review – never mind that projects such as MESSAGE have conducted more extensive and nuanced work on the same topic with a far wider group of experts – and, of course, with the Supreme Court judgement.
Beyond doom
As with Cass, as with Sullivan, it is difficult to capture the sheer enormity of harm caused by the Supreme Court’s pronouncement on biological sex. The consequences are still playing out, and will no doubt continue to do so for many awful months and years.
At the time of writing, the Equality and Human Rights Commission have proposed a programme of mass segregation, designed to discriminate against trans people in the workplace, in public services, and in social groups. The guidance they have written is just that: guidance, not law. Nevertheless, major organisations such as the Football Association, the British Transport Police, and Barclays Bank, all of whom shamelessly paraded rainbows through their social media profiles last Pride season, are falling over themselves to comply. We are witnessing the attempted complete exclusion of trans people from public life, in the latest culmination of a transparent attempt to eliminate us altogether.
In such moments, it can be easy to despair. This is in part because it is easy to forget the strength, resources, power held within trans communities and by our allies. That includes the knowledge and evidence we have access to.
Don’t get me wrong. The people who want to eliminate us are better-funded, better-connected, and now have the Labour government on-side as well as the UK’s traditional right-wing parties. We are not going to win trans liberation overnight.
But then, again, we never were.
Everything I said about lesbian culture earlier is true of trans people too. There are more of us publicly creating art and culture, more of us creating events and running nightclubs and playing in bands and writing essays (hi). There are more community groups providing mutual aid and support when charities and state bodies fail us. And, importantly, we are not alone.
Trans women and non-binary people are a part of the dyke renaissance. We are at the butch bars, and bemoaning the top shortage. We are dancing to Le Tigre and to Chappelle Roan. We are reading Gideon the Ninth and watching We Are Lady Parts and having all the feelings. My partner of the last decade was probably the most surprised of all to learn from the Supreme Court that I am not, in fact, a lesbian, as every bit of evidence from our shared personal lives points to quite the contrary.
I will concede that some trans people are not in fact lesbians, or even queer. Nevertheless, there are somany other places to find us in community with others. Trans people are in trade unions. Trans people are in workplaces. Trans people are in schools and colleges and universities. Trans people are in the streets. Trans people are on the bus. Trans people are in families. Trans people are making families. Trans people are playing football (suck it, Football Association). Trans people are eating pizza. Trans people are restoring the countryside. Trans people are hanging out beside Lake Geneva in the glorious sunshine, enjoying a much-needed break.
There are more of us than ever, and it is too damn late to put us back in a box.
Resistance is fertile
I was honoured to present the keynote presentation at the Swiss workshop. I spoke about the findings of the Trans Pregnancy Project, a study that produced enormous amounts of evidence on the experiences, needs, and perspectives of men and non-binary people who conceive, carry, and give birth.
No matter how much our findings are slammed by the media and billionaire children’s authors and washed-up comedy writers, our peer-reviewed work has demonstrated the lived reality of male and non-binary pregnancy over and over again. Most importantly, it has helped people. We are part of a far wider movement of parent groups, midwives, and researchers who are collectively building knowledge. I am constantly hearing from people who describe how much this knowledge has resulted in better care for them and their child. This kind of story drives everything I do.
Towards the end of my talk, I discussed the anti-trans moral panic, and the Supreme Court judgement. I then showed the below table of findings from the National Maternity Survey. This annual survey involves those who have recently given birth every year in many (but not all!) English hospitals, over the course of a few weeks. Since 2021, they have started asking whether the person giving birth has a different gender to the sex they were assigned at birth – i.e. are they trans?
Two things leap out from this table for me. Firstly, the 2021 data shows a very similar proportion of people indicating they are trans when compared to the 2021 censuses in Scotland, England, and Wales. This suggests that, contrary to assumptions around trans infertility or undesirability, trans men and non-binary people may well be just as likely to give birth as cis women are to become birth mothers.
Secondly, the number of trans people giving birth has risen dramatically over four years. Even as the anti-trans moral panic has deepened. Even as attacks on even recognising the existence of trans people in perinatal services have increased. As Del La Grace Volcano once it put it: “resistance is fertile!”
In the face of growing oppression, trans people are simply refusing to disappear. In fact, we are doing the opposite.
This, then, is the power that the anti-trans movement, the Labour party, and the Supreme Court cannot possibly take away from us. The more trans people are out and visible to one another, the more trans people come out and become visible to one another. Sure, we will unfortunately need to think more carefully about where and when we are out, and where and when we are visible, if this is something we even have any power over in our specific lives. I am sure that more trans people will be going stealth in future years, if they can. But regardless – there are more of us in community, more of us organising protests, and more of us than ever in the lives of our friends, families, colleagues, and allies, showing that it possible to have a good life while being trans.
In this context, it is important to know that people from many parts of the world gathered in Lausanne this April to pool our knowledge and skills and experiences. It is important to know that we have each returned to our home countries to share what we gained. It is important for people to know that similar meetings are happening across the world, in community centres and on university campuses, in board rooms and in bedrooms, involving trans people, and feminists, and yes, lesbians. We are constantly building a movement for positive change, and you do not have to be an academic or veteran activist to be a part of it. Trans power is for everyone.
There is much to say what needs doing in the current moment. We need allies to continue fighting alongside trans people for our collective liberation. We need to be demonstrating in the streets, funding mutual aid and legal action, actively resisting complicity in Labour’s eliminationist agenda, and encouraging every public body under the sun to do the same.
Evidence will be helpful for this. Evidence from academic research, sure, but also – as Dinah Bons pointed out – testimony from the everyday reality of trans people’s lives. And oh boy, do we have that evidence.
More of us than ever are producing evidence of trans existence, and trans persistence.
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. It costed £3 millionto produce.
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, and scholars working in fields including transgender medicine, epidemiology, neuroscience, psychology, women’s studies, feminist theory, and gender studies. They have highlighted problems with the Cass Review that include substandard and inconsistent use of evidence, non-evidenced claims, unethical recommendations, overt prejudice, pathologisation, and the intentional exclusion of service users and trans healthcare experts from the Review process.
This post provides a round-up of links to written commentary and evidence regarding problems with the Cass Review, plus quotes pulled from each. In light of these, I believe that current attempts to implement many of the Review’s recommendations are both misguided and harmful.
Readers who agree with me may wish to take actions including:
writing letters to MPs and other political representatives, NHS and professional bodies;
raising awareness within voluntary sector organisations and trade unions;
“The Cass Review’s internal contradictions are striking. It acknowledged that some trans young people benefit from puberty suppression, but its recommendations have made this currently inaccessible to all. It found no evidence that psychological treatments improve gender dysphoria, yet recommended expanding their provision. It found that NHS provision of GAMT [gender-affirming medical treatment] [..] was already very restricted, and that young people were distressed by lack of access to treatment, yet it recommended increased barriers to oestrogen and testosterone for any trans adolescents aged under 18 years. It dismissed the evidence of benefit from GAMT as ‘weak’, but emphasised speculative harms based on weaker evidence. The harms of withholding GAMT were not evaluated.”
“The administered ‘therapy’ included psychologically coercive and aversive practices with the goal of gender-typical, heterosexual outcomes. […] Although the 1987 article concluded that J’s case, among others, provided evidence that such therapy can ‘help’ similar children, J’s account indicates that all this treatment ultimately did was cause trauma and suppress her self-acceptance for 22 years. […] The 1987 publication should not be considered reputable evidence in any debate over transgender policies — either by direct or indirect citation. And yet, this article and publications of a similar age and theoretical background continue being referenced as if they were factual and reliable, by actors ranging from the Endocrine Society and the Cass Review to a parent support group[.]”
“Unfortunately, the Review repeatedly misuses data and violates its own evidentiary standards by resting many conclusions on speculation. Many of its statements and the conduct of the York SRs [systematic reviews] reveal profound misunderstandings of the evidence base and the clinical issues at hand. The Review also subverts widely accepted processes for development of clinical recommendations and repeats spurious, debunked claims about transgender identity and gender dysphoria. These errors conflict with well-established norms of clinical research and evidence-based healthcare. Further, these errors raise serious concern about the scientific integrity of critical elements of the report’s process and recommendations.”
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Professor Gordon Guyatt and colleagues [added 15/10/25] Systematic reviews related to gender-affirming care (statement led by the original pioneer of evidence-based medicine – while it does not explicitly name the Cass Review, it is highly relevant given the Cass team’s approach to conducting and interpreting systematic reviews, as noted in this analysis by Gideon Meyerowitz-Katz)
“Following fundamental principles of humane medical practice, clinicians have an obligation to care for those in need, often in the context of shared decision making. It is unconscionable to forbid clinicians from delivering gender-affirming care.”
“One of the overt criteria that the NHS followed in choosing Hilary Cass was her complete lack of experience in working with people with gender incongruence and dysphoria […] The common thread of many objections to the Cass report is the multifaceted downplaying of the importance of the voices of adolescents and their families, clinical practice, the scientific knowledge base, and national and global recommendations, while misleading the public that a complete lack of clinical experience in a given field is a guarantee of reliability. As a multidisciplinary team of experts and patients, we consider such a trend to be harmful and completely contrary to the interests of adolescents in need of help.”
“[I]t is very unusual in the history of medicine that a time-honoured treatment, with a good safety record, even if based on non-randomised trials and experts’ opinion, is simply banned, while waiting for better evidence.”
“Ultimately our responsibility is to offer compassionate, evidence-informed treatment to patients so that they get to decide what is best for them, given what is known and unknown about the risks and benefits of an intervention. To do otherwise would be failing in our scientific mission to ensure that gender affirming care is safe, effective, patient-centered, timely, efficient, and equitable[.]”
“Regardless of what Dr. Cass’ intentions may or may not have been, the Cass Review process itself intentionally and explicitly excluded any oversight from patients and their families and trans healthcare experts, and its content is not supported by a robust methodology. The Cass Review relies on selective and inconsistent use of evidence, and its recommendations often do not follow from the data presented in the systematic reviews. The Cass Review deprives young trans and gender diverse people of the high-quality care they deserve and causes immense distress and harm to both young patients and their families.”
“[…] while waiting for research results, not providing transgender adolescent care that may include puberty blockers and hormones to adolescents who experience gender incongruence is not a neutral act given that it may have immediate as well as lifelong harmful effects for the young transgender person. Also, asking transgender adolescents to participate in research as the only way to receive puberty blockers, as Cass recommends, is unethical.”
“Members of the BMA’s Council recently voted in favour of a motion which asked the Association to ‘publicly critique the Cass Review’, after doctors and academics in several countries, including the UK, voiced concern about weaknesses in the methodologies used in the Review and problems arising from the implementation of some of the recommendations. […] The BMA has been critical of proposals to ban the prescribing of puberty blockers to children and young people with gender dysphoria, calling instead for more research to help form a solid evidence base for children’s care – not just in gender dysphoria but more widely in paediatric treatments.”
“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.”
“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 Cass review recommendations are at odds with the current evidence base, expert consensus and the majority of clinical guidelines around the world.”
“[…] multiple relevant international organizations, including the Endocrine Society in the United States, have made statements to the effect that the issues pointed out by the Cass Review were already known, that puberty suppression treatment has been developed over many years, and that determinations on things such as the efficacy and safety of puberty suppression treatment should be made based on scientific findings […] WPATH 8th edition SOC in regards to the effectiveness, limits, and side-effects [of puberty suppression treatment] is written based on a greater number of systematic reviews than the Cass Review.” [p.17, translation by What The Trans, checked by myself with Google translate]
“Welche weiteren Personen außer der Autorin auf welche Art in der Erarbeitung des Reviews beteiligt wurden, ist nicht dokumentiert. […] Medizinische Fachgesellschaften wurden an der Erstellung des Berichts nicht erkennbar beteiligt. Es wurde eine sogenannte „Assurance Group“ berufen, welche jedoch ausdrücklich nicht an der Erarbeitung von Empfehlungen des Cass Reviews beteiligt war. Es liegen Berichte vor, dass außerdem ein „Advisory Board“ eingerichtet wurde. Die Zusammensetzung sowie der konkrete Beitrag dieses „Advisory Boards“ sind nicht dokumentiert[.] Es lässt sich insofern keine Einschätzung über die Expertise der Mitglieder abgeben.”
“It is not documented which other people, apart from the author, were involved in the preparation of the review and in what way. […] Medical societies were not identifiably involved in the preparation of the report. A so-called “Assurance Group” was appointed, but it was expressly not involved in the development of recommendations for the Cass Review. There are reports that an “Advisory Board” was also set up. The composition and specific contribution of this “Advisory Board” are not documented[.] It is therefore not possible to make any assessment of the expertise of the members.“
“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.”
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Endocrine Society (USA and international) Statement from Endocrine Society[added 15/05/24] Note: statement prepared in response to an interview with Hilary Cass for the ‘On Point’ podcast.
“NHS England’s recent report, the Cass Review, does not contain any new research that would contradict the recommendations made in our Clinical Practice Guideline on gender-affirming care. […] Although the scientific landscape has not changed significantly, misinformation about gender-affirming care is being politicized.”
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American Academy of Pediatrics (USA) Statement from American Academy of Pediatrics[added 15/05/24] Note: statement prepared in response to an interview with Hilary Cass for the ‘On Point’ podcast.
“The AAP’s gender-affirming care policy, like all our standing guidance, is grounded in evidence and science. […] What we’re seeing more and more is that the politically infused public discourse is getting this wrong and it’s impacting the way that doctors care for their patients. […] Politicians have inserted themselves into the exam room, and this is dangerous for both physicians and for families.”
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Dr Max Davie and Dr Lorna Hobbs [added 08/08/24] (Consultant paediatrician and clinical psychologists – former education leads for London’s new child and adolescent gender services) Cass: the good, the bad, the critical
“The fact that any new prescriptions of puberty-pausing medication for someone under 18 is now a criminal offence in the UK may be shocking, but to those of us who were observing the Cass review it is not surprising. Dr Cass was known by colleagues to oppose medical transition when she was appointed to the review, after all.”
“[…] 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’.”
“’There have been multiple expert academic treatises written on what was wrong with the Cass Review … they intentionally sidelined people who worked in the field,’ [Brisbane GP Dr Fiona Bisshop] told The Medical Republic. ‘Practitioners who worked with trans patients and trans people themselves were excluded from that whole review, and that didn’t happen [in Queensland]. They talked to the right people who were using the service and they also included some people in the review panel who were experts.’”
Responses and publications from expert researchers and educators
“Using the ROBIS tool, we identified a high risk of bias in each of the systematic reviews driven by unexplained protocol deviations, ambiguous eligibility criteria, inadequate study identification, and the failure to integrate consideration of these limitations into the conclusions derived from the evidence syntheses. We also identified methodological flaws and unsubstantiated claims in the primary research that suggest a double standard in the quality of evidence produced for the Cass report compared to quality appraisal in the systematic reviews.”
“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 […]”
“While the Cass Review has been presented by the U.K. media, politicians and some prominent doctors as a triumph of objective inquiry, its most controversial recommendations are based on prejudice rather than evidence. Instead of helping young people, the review has caused enormous harm to children and their families, to democratic discourse and to wider principles of scientific endeavour.”
“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.”
“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.”
“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.”
“In this commentary, this scientific evidence is reviewed, particularly focusing on the biological and psychosocial claims reported in the [Cass] Review. The scientific substantiation of assertions in the sections on understanding the patient cohort and clinical approaches is examined critically, resulting in the finding that the Review shows a number of issues that together point to a substandard level of scientific rigor in the Review. As such, it called in question whether the Review provides sufficient evidence to substantiate its recommendations to deviate from the international standard of care for trans children.”
“Zoals vele artikelen, waaronder mijn eigen recentelijke publicatie, hebben aangetoond, is het onderzoek van Cass echter zélf wetenschappelijk zwaar onder de maat. Het geeft bijvoorbeeld geen statistische onderbouwing van kwantitatieve claims. Ook gebruikt Cass eenzijdige bronnen voor haar aanbevelingen. Het rapport versimpelt verder veel lastige biologie, zoals het idee dat het brein pas volwassen is als je 25 bent.”
“However as many articles, including my own recent publication, have shown, Cass’s research itself is scientifically seriously substandard. For example, it provides no statistical substantiation of quantitative claims. Cass also uses one-sided sources for its recommendations. The report also simplifies a lot of difficult biology, such as the idea that the brain is not fully mature until you are 25.“
“It needs to be emphasized here that even The Cass Review found no empirical evidence of harm being caused to young trans people by puberty-blockers. This study, however, demonstrates that banning them causes very significant harm indeed. […] By far the most consistent prevailing theme to come out of the data was that of the overwhelming levels of distress these young people are experiencing[.]”
“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.”
“The Cass Review […] demonstrates that transphobic pop-cultural discourses have real material effects. Transphobic discourses became increasingly publicly popular, which led to increased criticism of current care models for trans youth. Heightened public scrutiny led to the Review’s commissioning and the subsequent banning of puberty blockers. There is a direct line between public discourse and restrictions on trans rights.”
“The Review does not make it clear that such a significant proportion of the experts it relies on do not believe in [the existence of] transgender children or that the root cause of distress in this population is gender. It may be unclear to policymakers and the public that people holding such views are shaping practice norms.”
“[…] above all else, the Cass teams disregarded evidence supporting trans care. They did so by starting their research from the position that trans care is a problem which must be solved in the first place. […] They started from the logic of a pandemic, expressed in the fear of a “social contagion” capable of upending cisgender supremacy, and in so doing, they created the conditions to make evidence that would assert a position of cis-supremacy.”
“I will argue that some of the recommendations contained in the Cass Review are not congruent with ethical norms concerning clinical research involving minors. There are sound reasons to perform clinical research in this area, and the investment in research is to be welcomed. However, a clinical trial is unlikely to enhance the evidence base.”
“Our concern here is that the Review transgresses medical law, policy, and practice, which puts it at odds with all mainstream U.S. expert guidelines. The report deviates from pharmaceutical regulatory standards in the United Kingdom. And if it had been published in the United States, where it has been invoked frequently, it would have violated federal law because the authors failed to adhere to legal requirements protecting the integrity of the scientific process. […] More generally, the Review’s circumscribed approach to drug approvals is out of step with pharmaceutical law and policy in both the United Kingdom and the United States. […] The [final] report’s application of a heightened evidentiary standard probably stems in part from its deviation from standard medical scientific process. Specifically, it lacked peer review, transparency of authorship, and equitable selection of nonauthor contributors.”
“Trust in research is not only fragile, but it is built on, over time. When this gets eroded or broken (as in the Cass Review), it creates a highly volatile environment for the medical and scientific community to try and shift.”
“In the USA, the 2025 HHS Gender Dysphoria Report […] it dismisses decades of clinical practice and undermines the legitimacy of care models that affirm youth gender identities. Like the Cass Review, it frames gender-affirming care as inherently suspect, requiring extraordinary proof to be considered safe. The resulting policies render timely care inaccessible, especially in politically hostile states. Neither report applies comparable scrutiny to irreversible paediatric interventions in other contexts, such as intersex care, nor do they address the harms of care denial or of imposition of questionable care.”
“Cass’ conclusions generally focus on limiting or minimizing medical GAC for youth and she also minimizes the robust data and the potential negative impact of increasing barriers for an already disenfranchised group.”
“The [Cass Report] is not a clinical guideline or a working manual. Unlike the systematic reviews from which it draws its conclusions, the report is not a scientific publication and was not submitted to a peer-reviewed journal. Furthermore, it does not produce new evidence or find any evidence of harm caused by social transition and the use of medical treatments such as puberty blockers and cross-sex hormones. […] [Critical reports] have compellingly exposed some of the report’s methodological flaws and the undue interpretation of the report by those who have used the document to advance their own anti-rights agendas.”
“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.”
“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.”
“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.”
“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?”
“The [Cass Review] authors cite conversion clinics as evidence that transgender children rarely experience dysphoria as adults, use incredibly low-quality research to support the idea that detransition is more common than we might imagine, and almost entirely avoid the data which shows that most transgender people – including children – persist in their identities and do not regret their transition.”
“One of the strangest parts of the Cass review is the speculation on the potential negatives that medications may have […] For a review that spends a great deal of time bemoaning the state of the evidence supporting transgender care, this is an astonishing thing to do. The cited reference [on brain maturation being disrupted by puberty blockers] is a speculative theory about the importance of pubertal hormones on mice, with no follow-up data in humans.”
“There seems to be a very strong pattern in the Cass review which we are seeing repeated in almost every part of the publication. First, we have a review of the evidence for gender-affirming care in kids. Mostly, the evidence isn’t great. This is an unfortunate fact, and one that I’ve discussed at length. Then, the review will cite various unsubstantiated theories that vary from possible to unlikely to complete pseudoscience. These theories are given equal – or in some cases, greater – weight than the existing evidence in actual trans children.”
“For a document that spends literally thousands of words lamenting the quality of evidence for trans healthcare, it is startling to see that the only therapies that Cass recommends are the ones with by far the worst evidence around.”
“What we can say with some certainty is that the most impactful review of gender services for children was seriously, perhaps irredeemably, flawed. The document made numerous basic errors, cited conversion therapy in a positive way, and somehow concluded that the only intervention with no evidence whatsoever behind it was the best option for transgender children. […] The fact that so many have taken such an error-filled document at face value, using it to drive policy for vulnerable children, is very unfortunate.”
“[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.”
“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.”
“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.”
“The signatories urged [UK education secretary] Phillipson to undertake three actions: – Restate commitment to, and pursue with haste, a legislative ban [on] all conversion practices. – Welcome the fair criticism of the Cass Review, reflecting the nuance of a complex field and recognising the substantial, widespread international critique. – Meet with us, with a shared commitment to keep inclusion at the heart of our practice, so that we can help build an education system and society where everyone can find a place to belong.”
“I am persuaded that the Cass Review, whilst by no means irrelevant, is deserving of little weight in determining where Ash’s best interests lie. (186) […] The wholly untested Cass Review does not help much, or even at all, since it could only (in this case) recommend that there is nothing that can be done to help Ash. Indeed I must confess the “do nothing” approach […] (albeit practically cloaked as “psychotherapy” – which Ash will not likely accept, even if it could be funded, which on the evidence it could not), troubles me because it seems to work on the assumption that doing nothing is better, which seems to be just kicking the can down the road until Ash is 18, in the hope that, given time, he will change his mind. (248)”
Important note: the conclusion to the judgement adds: “observers may also read this judgment as some kind of refutation of the Cass Review and the views of health professionals who adhere to similar views as expressed in that review, but again it is no such thing. Whilst the Cass Review appears to have some deficiencies, blind spots and limitations, ultimately that is a matter for the UK Government, not an Australian court, to determine” (276). I am sharing the judgement here as I feel it highlights important limitations in the Review even if it does not amount to a formal refutation.
Responses from trans community organisations
Coalition of 100+ LGBTQ+ community organisations and experts Letter to Wes Streeting[added 11/11/24]
“Trustworthy government reviews of the evidence base for a particularly controversial policy, especially in the medical field, do not look like the Cass Review. They have a clear mandate and problem to solve which are raised by those directly affected, not by newspaper columnists or ideologues. They do not exclude members of the patient cohort and those with long-term experience in the field from being part of their team or consider professional or lived experience “bias”. They ensure there is transparency and meritocracy in the appointment of key personnel. They consult openly and in an ongoing fashion with patients and organisations representing them. They do not assume that the treatments in question and anyone involved with them are part of an ideological conspiracy. They are clear and consistent about the evidentiary standards being used to judge any given concerns. They are careful not to give credence to unevidenced theories. They accurately represent the views of those they have engaged with. When problems arise or mistakes are made, they engage with the impacted communities. When strong critiques are made by other experts internationally, these are discussed and engaged with rather than ducked and declared unacceptable to mention.”
Disclosure: I contributed to and signed this letter.
“Decisions are being taken that affect our lives without any trans people in the room, let alone trans young people. Too often trans kids are portrayed as a monolith of confused, depressed teenagers. We are denied choice and robbed of our autonomy. But we should be trusted to make the same decisions about our healthcare that all people are.”
“[…] 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.”
“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.”
“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.”
“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.”
“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.”
“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.”
“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.”
“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.”
“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. “
“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.”
“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.”
“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 trade unionists and human rights groups
“[T]rade unions’ rejection of what has been framed by the media and political establishment as a ‘moderate’ and ‘reasonable’ line on trans rights should be seen as a cause for hope. […] Regardless of what comes next, though, we must be guided in everything we do by what trans communities and trans-led organisations are asking for. As members of organisations founded on worker self-representation, “nothing about us, without us” must be at the front of our minds and hearts.”
“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.”
“As much as Cass’s report insists that all lives — trans lives, cis lives, nonbinary lives — have equal value, taken in full it seems to have a clear, paramount goal: making living life in the sex you are assigned at birth as attractive and likely as possible. Whether Cass wants to acknowledge it or not, that is a value judgment: It is better to learn to live with your assigned sex than try to change it. If this is what Cass personally believes is right, fair enough. It can charitably be called a cultural, political or religious belief. But it is not a medical or scientific judgment.”
“Though there is much more evidence now to support gender-affirming care than in 2008, there is also a much stronger anti-trans movement seeking to discredit and ban such care. British media coverage has given that movement a big boost in recent years, turning the spotlight away from the realities that trans kids and their families are facing, and pumping out stories nitpicking at the strength of the expanding evidence base for gender-affirming care. Its coverage of the Cass Review followed suit.”
“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.”
“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[.]”
“The French Society of Pediatric Endocrinology and Diabetology (SFEDP) recently commissioned its own version of the Cass Review, and this study reached almost the exact opposite conclusions of Cass […] Upon reading both the Cass Review and the SFEDP Review, what immediately jumps out is the very different tone of each—Cass takes a tone that feels skeptical to the point of excess, offering mysteriously curt phrasing, statements rife with implications of harm or conspiracy by mainstream providers, and an overall sense of invalidation. By contrast, the SFEDP Review reads like a scientific paper—its language is straightforward and sterile, and there is none of the innuendo of Cass.”
“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.”
“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.”
“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[.]”
“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.”
“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.”
“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.”
“[A] focus on “distress” was used to obfuscate the core purposes of treatments in transgender care. By keeping the reader’s attention on a subset of a treatment’s (often hypothesized) effects, Cass elides ancillary outcomes with the reasons why those treatments are used […] It is urgent to understand that implementing Cass will entrench deeply transphobic ideas and practices within the NHS. The result will be a systematic and dangerous failure to serve the needs of a patient group that is marginalized, maligned, and misunderstood at every turn.”
“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.”
“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[.]”
“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.”
“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.”
“§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’.”
“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.”
“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.”
“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.”
“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 reportor thelater 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.
I am very excited to announce that I will soon begin work on a new project. From the beginning of April I will be working full-time with Spectra as Research Coordinator for the Trans Learning Partnership.
The Trans Learning Partnership is a groundbreaking collaboration between trans and non-binary community representatives, academics, and four organisations who work to directly provide community services: Spectra, Gendered Intelligence, Mermaids, and the LGBT Foundation. The aim of the Partnership is to drive the development of a robust service and advocacy-oriented evidence base, enabling trans services and their service users to have needs-based, impactful services.
This also means that I will be leaving the Trans Pregnancy Projectat the University of Leeds, but rest assured that I plan to continue supporting my colleagues from that project in writing up and publishing our findings. We have a number of academic articles currently in the pipeline, along with a themed special issue of the International Journal of Transgender Health.
I will of course continue to update this website periodically with information and reflections on all of my ongoing research.
The Trans Learning Partnership feels like such an important opportunity to design and undertake research intended to directly improve people’s lives. I can’t wait to get started!
Dr Ruth Pearce 