I was relieved to see today that the Charity Commission’s investigation into Mermaids has finally concluded. The Commission’s published decisionfound that Mermaids was mismanaged in several respects, but did not find evidence of misconduct, especially in terms of safeguarding young people or providing medical advice.
This is great news in that Mermaids can now continue to operate as a charity and seek funding from relevant agencies to do so. The organisation clearly faced an enormous squeeze during this time, that significantly affected service provision.
However, I am concerned by the language used around the Cass Review in the Commission’s report and accompanying press release. I feel much of this language is deeply misleading and demonstrates considerable ignorance regarding the Review. At the same time, I feel there are some good, practical recommendations in there for charities which face potential harassment from media reporting and on social media.
Binders
The most concerning statement can be found in the Charity Commission’s press release, concerning Mermaids’ former provision of binders to young people as a harm reduction measure:
The Commission has issued statutory advice to the charity requiring that, should it ever resume this service, its future policy and controls should reflect the recent Cass Review, or any future NHS guidelines on parental involvement.
The Cass Review does not, of course, actually make any formal recommendations for non-medical service providers – moreover, its commentary on social transition is not well-evidenced.
However, the Charity Commission decision quotes the final report of the Cass Review, which states that “parents should be actively involved in decision making unless there are strong grounds to believe that this may put the child or young person at risk“. This would appear to align with Mermaids’ actual policy, which was to work with parents, families, or carers unless a young person was not directly supported. The issue, of course, is that the Charity Commission (and, indeed, the Cass Review team) do not fully interrogate or understand the considerable risks posed to young trans people by unsupportive parents.
I am increasingly of the impression that policymakers are taking all kinds of decisions without having read the Cass Report in any detail, let alone with a critical eye. This would appear to be another example of this.
Having “regard” to the Cass Review
Similarly, in a sub-section of the decision report titled “Implementing the findings of the Cass Review”, the Charity Commission recommends that trustees working with “children and young people who are questioning their gender identity or experiencing gender dysphoria” need to “ensure that they have regard to the findings, conclusions and recommendations of the Cass Review and ensure that they have reviewed their charity’s literature, website and guidance in light of them“.
This statement is, I believe, being wilfully misinterpreted on social media and in media commentary. For example, the Standard’s report on the decision leads with the headline “Charities should follow Cass Review recommendations, say watchdog”. However, that is not what the decision actually says.
In the UK, “have regard” means that organisations should take account of guidance and carefully consider it. An example of this can be found in the Charity Commission’s rules for charities on public benefit:
As a charity trustee, ‘having regard’ to the commission’s public benefit guidance means being able to show that:
you are aware of the guidance
you have taken it into account when making a decision to which the guidance is relevant
if you have decided to depart from the guidance, you have a good reason for doing so
In the current political climate, this strikes me as an eminently sensible approach to the Cass Review. I would expect all service providers and researchers to be aware of the Review’s final report, to take it into account, and (for the purpose of defending against bad faith actors) be able to provide good evidence for acting otherwise.
Going by a statement from Mermaids Chair Kathryn Downs for Third Sector, this appears to the charity’s planned approach to having regard:
“The Cass Review final report is the highest-profile review of youth healthcare in the world and has influenced NHS England’s policies. However, it is not legislation or guidance.“
She then goes on to emphasise that Mermaids’ advocacy and policy work will continue to be “driven by and give a platform to the voices of young trans people“.
We deserve better from the Charity Commission
Overall, I feel this is good news for Mermaids, and for trans organisations more generally. However, the language used by the Charity Commission, especially in their press release, really muddies the water by providing considerable grounds for bad faith interpretation.
It’s also deeply frustrating to see the Cass Review continually upheld as a paragon of policy advice. Trans people know that the Review was conducted by non-experts and involved individuals hugely hostile to our very existence. As a researcher, when I open the final report I see a methodological and ethical nightmare. The Cass Review is an example of runaway bad science, treated as an article of faith by mainstream decision-makers, many of whom haven’t actually read it.
I don’t think it’s unreasonable to speculate that the Charity Commission’s final decision reflects the influence of transphobic actors. Two years is an extraordinarily long time for an investigation to take place, and surely does not serve the interests of the young people Mermaids work with. Earlier this year the Commission’s Twitter account “accidentally” shared a transphobic post claiming (without evidence) that the charity had caused “so much harm”, calling into question the independence of the investigation.
I’ve been critical of Mermaids myself in the past, especially given I did not feel appropriately supported by them when I came out as a teenager. I am sure I will continue to be critical in the future. However, I hope this criticism can always be both constructive and grounded in reality, recognising our shared interest and care in building a better future for young people.
…the time taken to publish this report has been frustrating, significantly affecting Mermaids’ fundraising and ability to deliver on our charitable objectives. We call on the Charity Commission to ensure that organisations serving groups facing rising hostility are supported and protected, whilst being held to account where this is necessary.
It’s difficult to put into words what an enormous experience the 2nd International Trans Studies Conference was: the power of being in community with other trans scholars, the benefits of sharing ideas across disciplines and borders, the frustrations that arose with technical difficulties and the academy’s complicity in so many forms of violence. I intended to reflect on some of these matters further in a final blog post, but for now suffice to say that I was by turns exhausted, joyous, and hopeful throughout the fourth and final day of the event.
On being a target: How trans studies scholars and practitioners can survive hate and harassment
Saturday morning featured a session I had put together, focusing on strategies for survival in trans studies at a time of increased negative attention on our work. I approached several colleagues who have encountered substantial challenges from anti-trans campaigns, three of whom kindly agreed to join me to talk about what we might do about this.
Asa Radix of Callen-Lorde Community Health Center (USA) and Samantha Martin of Birmingham City University (UK) were sadly not able to join us in person, but recorded brilliant videos describing practical and theoretical responses to their experiences of being targeted by hate movements, both externally and within the institutions in which they worked. Florence Ashley of the University of Alberta (Canada) brought their irrepressible physical presence to the room, exploring in a short talk how proposed police monitoring of their law classes threatened to undermine the academic freedom of their students.
I wrote my own short presentation based on my experiences, explaining the abuse and harassment that continues to disrupt my research, and ways in which I have sought to counter this in practice. Drawing on my 2020 article “A Methodology for the Marginalised”, I argued that it should not be our individual responsibility to look after ourselves. Rather, we need practical support from the employers who benefit from our work. We also gain from building communities and networks of mutual support among marginalised academics, both within and beyond trans studies. A copy of my slides can be found here.
For me the most important part of the session was not what the speakers said, however: it was the opportunity for attendees to discuss their own experiences and strategies for navigating institutional barriers and opportunities for support. Whereas most of the conference consisted of several academic presentations followed by a short Q&A, we intentionally structured this session to enable as much conversation as possible, with questions fielded by anyone and everyone in the room rather than just looking to the speakers as experts. As a lecturer in community development, I found myself almost surprised by the rigidity of the traditional conference format, and was glad that attendees felt they benefited from our more open-ended approach, and the opportunity to discuss and sit with ideas.
Sadly, our online attendees did not have the same experience as those in the room. Like many other sessions at the conference, ours was plagued with technical difficulties due to problems with the digital conference software Ex Ordo. Given this possibility, and the fact that our session featured two video presentations, I turned up early in the morning to strategise with our amazing technical assistant, Srishti Chatterjee. Unfortunately, the session before ours ended up overrunning due to their own technical issues, meaning that we no time to properly set things up. Under pressure, we managed to get the videos working, but weren’t able to monitor the online chat while this was happening, not realising until afterwards that they were not visible for those outside the room. It would have undoubtedly been worse if Srish was not present, highlighting the importance of having trained people with initiative on hand to respond to problems as they arise.
You can read a third party account of our session on Amy Ko’s blog (thanks Amy!)
Trans Synths and Synthetic Sounds
After our intense discussion of hate and safety, I sought refuge in a more joyous session. And so to synths, and synthetic sounds: to trans pop and hyperpop, music that brings me immense joy.
This session began with a talk titled Switched-On Reality: The Synthesizer and Trans Subjectivity, by Westley Montgomery of Stanford University (USA). Montgomery highlighted the enormous contributions to music made by two pioneering synthesiser artists: Wendy Carlos and Sylvester.
Carlos is famous for her arrangements of Bach for the Moog synthesiser, as well as her film scores for A Clockwork Orange, The Shining, and Tron. Sylvester was a member of the drag theatre group The Cockettes, before becoming known as the “Queen of Disco” with hits such as “You Make Me Feel (Mighty Real)”. Both are therefore remembered for their major contributions to 20th Century popular music, but as Montgomery observed, can also be seen as “bad trans objects”.
Carlos transitioned in the 1960s and disclosed her trans history in the late 1970s, following her rise to prominence. In this way she became an extremely high profile trans musician. However, she also distanced herself actively from trans liberation movements, enabled by her relative privilege as a highly educated, white, middle-class woman. Montgomery wryly observed that people have asked ‘“where was Wendy Carlos [who lived in New York at the time] during Stonewall?’”, noting that, “the answer is most likely at home, playing Bach”. Sylvester, a Black middle-class person with an ambivalent public relationship to gender, famously proclaimed “If I want to be a woman, I can be a woman. If I want to be a man, I can be one”. However, Sylvester actively rejected transsexual identification, was uninvolved in the civil rights movement, and would later also reject disco music as it waned in popularity.
Both Wendy Carlos and Sylvester can therefore be understood as assimilationist figures who do not live up to liberatory ideals. But Montgomery argued that they must be understood within the context of the material conditions in which they lived. Moreover, their musical contributions are historically significant regardless, especially in terms of synthesiser use. Montgomery posited that the mainstream emergence of the synthesiser and of women and queer musicians happened in tandem, enabling a resignification of womanhood. Montgomery ended the talk by Hannah Baer, who argues moreover that the synthesiser is inherently not cisgender: “a synthesiser’s shape is not in any way where the sound comes from, and there’s something so free and trans in that. You have no idea what sound is going to come out of this thing. And maybe I don’t either!”
The next few talks shifted the focus to 21st Century synthetic sounds in the context of hyperpop. In Gender Knobs: Transgender Expression through Vocal Filtering Technology in Drag, Hyperpop Music and Beyond, Jordan Bargett of Southern Illinois University at Carbondale (USA) looked at the gendering of voice through pitch filtering. Her story began with the vocoder, originally invented to extend bandwidth in telefony, and later adapted for encryption in World War 2 before being adapted for popular music by artists including Wendy Carlos and Laurie Anderson. Anderson in particular used pitch filtering for gender drag in “O Superman”, using it to perform a masculine “voice of authority”. In the 2000s and 2010s pitch-shifting gained popularity with nightcore, setting the scene for trans-specific experimentation within hyperpop.
With hyperpop, Bargett explained that filtered vocals could be used for more nuanced gender expression as well as drag. They introduced the examples of trans women artists SOPHIE and Laura Les, who both used pitch filtering to create more “feminine” singing voices. In this context, authentic trans voices might be understood as both “synthesised and authentic”. At the same time, Bargett cautions that pitch alone does not, of course, gender a voice, and that hyperpop artists tend to be well aware of this. She presented the example of SOPHIE’s music video “It’s Okay to Cry”, in which the artist’s voice and body are “undressed”: an expression of trans vulnerability. The talk concluded with a screening of Bargett’s own short film “Transistor”, which explored how “technology can be an extension of the trans self and body”.
We heard more about SOPHIE from Gabriel Fianderio of the University of Wisconsin-Madison (USA), in Interpretation and articulation: Transphobia and Dysphoria Through SOPHIE’s “L.O.VE.”. Fianderio began by noting that “BIPP”, the opening track on SOPHIE’s debut EP PRODUCT, promises to make us “feel better”. But “L.O.V.E”, the closing track on the EP, is difficult to listen to due to the hostile noise of the dentist’s drill that recurs throughout the song. How to make sense of this disjuncture?
Fianderio posits that SOPHIE’s music provides a context in which we can move from “interpretation” (one truth) to “articulation” (space for multiplicity). Interpretation is often a problem with trans people. Citing Salamon, Fianderio noted that “trans panic” defences for the murder of trans women often depend on the interpretation of gender expression as “an aggressive act, akin to a sexual advance or sexual assault”. Similarly, dysphoria can entail a range of complex feelings and sensations relating to ourselves and others. Forms of interpretation centring pain, disgust, and distress ignores the complexity of ambivalence, and the possibility for accompanying euphoria.
Fianderio’s argument was that “L.O.V.E.” problematises interpretation through its use of the drill sound. They drew on internet commentary to show how the sound is often described by listeners as a physical experience (e.g. “This unblocks my nose”). Complex textures underlie this painful sound of the drill, and complex articulations are subsequently appreciated by listeners who spend time with the song and come to enjoy it. In this context, “L.O.V.E.”’s rejection of singular interpretation enables listeners to read conflicting emotions into the same form, and hence articulate complex feelings around euphoria and dysphoria. This can take place with and through the drill sound itself, and/or the song structure itself, with its synthesised vocals and moments of relief and beauty.
The final talk in the session, by Lee Tyson of Ithaca College (USA), was titled Trans Hyperpop and the Synthetic Authenticity of the Digital Voice. Tyson asked how and why trans hyperpop artists are positioned as “authentic”. Their talk began again with SOPHIE, noting that she was widely celebrated for her “authenticity” following her accidental death in 2021, which appeared to potentially contract with the experimental approach and ironic sincerity she employed in much of her music. Tyson describes this as a form of “synthetic authenticity” that can be found among many trans hyperpop musicians.
Tyson returned to the topic of vocal manipulation, quoting Laura Les’ comments on her earlier work, in which she explained she altered her vocals because “it’s the only way I can record, I can’t listen to my regular voice, usually” [my note: interestingly, the most recent material from Les’ band 100 gecs features much less processing on her vocals]. By contrast, Dorian Electra artificially inflates the character of their voice: “My music is simultaneously artificial and authentic. It’s just as authentic to use the same sappy love song language that’s been used in a million ways. A person singing a love song is still putting on a character”.
Tyson contextualised these comments by noting that voice manipulation can be understood as part of a wider technological field, as with (for example) hormone therapy, surgeries, and voice training. Within this field, hyperpop can be understood as a form of simultaneous deconstruction/reconstruction [note: I have also written on this as a feature of trans music!] This is not always liberatory: Tyson outlined the examples of the commercialisation of hyperpop, and the white appropriation of tropes of Black soul music by artists such as SOPHIE. At the same time, by finding something “more real” in artificial sounds, hyperpop offers a productive challenge to contemporary trans advocacy strategies and neoliberal imperatives of self-actualisation which rely on norms of intelligibility.
Overall, this was one of my favourite sessions of the conference. Like much of the music under discussion, it was self-knowingly silly and playful – yet stuffed full of surprising depth and interesting ideas. I only wish that the presenters had spent less time critiquing the whiteness of hyperpop, and more time considering the work of groundbreaking artists of colour such as underscores. Meanwhile, I don’t think music in and of itself can change the world, but it can help change the way we think, and that’s powerful and important.
Caucuses
After lunch, I spent most of the afternoon in a range of caucus sessions. These actually ran throughout the conference, and offered more open discussion spaces for people to have conversations on the basis of shared personal/demographic experiences or disciplinary interests. For example, there was an Asian scholars’ caucus, and a caucus for people studying trans healthcare.
Unfortunately, the schedule for the event was so jam-packed that each of the caucuses took place alongside multiple parallel presentation sessions. As such, I didn’t get around to attending any of the ones relevant or open to me until the final afternoon, when I managed to go to three in succession.
The first of these was the Palestinian caucus. This was an informal but very well-attended event arranged by attendees who wanted to organise collectively against the ongoing genocide in Gaza. This felt particularly urgent at the conference given the absence of Palestinian speakers, the presence of corporations who invest financially in the Israeli regime, and the suspension of Northwestern University professor Steven Thrasher following his support for a student encampment.
The second was the trans women and transfeminine scholars’ caucus. I recommended this take place and volunteered to chair it after a callout for volunteers from the conference organisers. Like many trans professional and trans studies spaces, the conference was dominated by men and transmasculine people. One joke often repeated at the conference was that “trans studies is mostly trans men who talk about trans women to cis women”: it felt very different to consider the repercussions of this within a woman and transfeminine only space. I found it very meaningful and refreshing to connect with colleagues in this context, and there is at least one very cool idea which might come out of our conversations, so watch this space.
Finally, I attended a caucus on publicly engaged scholarship. This turned out to be a small number of us swapping career advice, which is perhaps not what I originally intended, but felt very productive nonetheless!
Closing plenary
The conference closed with a plenary titled Whither Trans Studies? Towards a Future for the Field.
First, organiser TJ Billard took to the stage to make some closing comments. They thanked their fellow organisers, plus the conference’s steering group and sponsors, reflecting on how important it is that various university departments (especially at Northwestern) and research institutions support trans studies. They then reflected on the conference’s ambitious approaches to accessibility and inclusion, which faced some significant hitches in practice.
Billard thanked conference attendees for being patient and forgiving when things went wrong, and encouraged future organisers to “learn from the things that we tried to do, learn that the things that we failed to do, shortcomings both technical and intellectual”. They noted, echoing the complaints of the Palestinian caucus, that this included the absence of Palestinian scholars at a time of ongoing scholaricide, and apologised for the organisers’ failings in this regard.
We then heard reports from a small number of the caucuses. The graduate student caucus asked, “where is trans studies going? There was lots of discussion, and no consensus”. The Asian scholars’ caucus noted how the needs of Asian scholars are not necessarily met in “standard” Anglophone trans studies classes or syllabi, and reflected on the importance of building a network and not being alone.
The most extensive report came from the disabled scholars’ caucus, and these reflected many of the major strengths and failings of the conference I and others have written about recently. For many disabled scholars, we heard, this was a first opportunity to know of one another’s existence. Nevertheless, “the absences at this conference [were] as significant as the presences”: a comment that reflected Kai Pyle’s statements on the absence of Indigenous scholars in the opening plenary. Disabled people were absent due to numerous barriers to participation: this included the extreme circumstances facing those experiencing disablement through genocidal actions note just in Gaza, but also in Sudan and Congo.
In this context, the disabled trans scholars who were present were broadly “grateful and somewhat okay with the access we have experienced this week”. However, we were left with a number of thoughts which will be vital for future organisers: “Access is about justice, and justice is about accountability […] Access is not simply a matter of getting into a building. It is about interrogating why a building is inaccessible in the first place”.
Then the conference closed with a barnstorming final speech from the legendary Susan Stryker. She began by thanking all the people who had approached her throughout the event to thank her for her significant body of work: “I appreciate that something that I did landed with you in some way”. She then turned to think through the purpose and importance of trans studies.
Stryker started by looking to the roots of her own oppression. She explained that this has informed her analysis of body politics that positions people within specific, given social roles. She argued that while this body politics is a lynchpin of the Eurocentric social order, it has not always been this way, and it does not have to by this way.
What does it mean to be trans in this oppressive social order? Stryker proclaimed that “transness is an affective experience, driven by suffering and drawn by desire […] it is a practice of freedom”. This presents the possibility of alliance across multiple liberation movements. As Black trans studies has shown, transness is not just about sex/gender, but also at least as much about race, and the ways that certain bodies are racialised through gendering and gendered through racialisation. It is also vital that trans people understand their commonality with feminism. Insofar as feminism defies biological determination, “feminism can be considered a trans practice of freedom”. What brings us together is our movement across the boundary of categories designed to restrict freedom: “it is wrong to believe that embodiment must be a trap”.
Consequently, trans studies is about the pursuit of freedom, and should be a liberatory practice. Stryker cautioned us that creating an institutionalised form of trans studies does not solve the actual problems we face. She wryly insisted that we learn from the student movements of the 1960s, which did not achieve revolution, but instead “achieved ethnic studies departments”. She encouraged us to consider how we might use what positions we have in the academy to create space for struggle: “If we are so damn radical, if we are so dangerous, why has the field not been oppressed more brutally?” Stryker explained that she wasn’t trying to deny the real oppression we face – but rather, to acknowledge that as we sat gathered in the state of Illinois, certain things were possible for us which are not necessarily possible elsewhere.
At this juncture, Stryker reminded us of Stephen Thrasher’s suspension for visiting a student camp that supported the Palestinian struggle against genocide. She invited us to consider what it is about a trans studies conference – sponsored by the very institution that suspended Thrasher – that makes us more acceptable than voicing support for people facing death in Gaza?
Stryker shared several concerns raised at the Palestinian caucus with the rest of the conference, asking: what might a post-disciplinary trans studies look like in light of an absence of meaningful, substantive engagement with the genocide in Gaza? Drawing on a statement put together by the caucus, she noted that the conference was not BDS compliant, that attendees were not made aware of Northwestern University’s complicity in genocide, that there was no explicit discussion of the scholarcide in Gaza in the official programming, and that there was no formal engagement with the large Palestinian diaspora community living near to the campus. She argued that a shared liberatory goal for trans studies should include solidarity with Palestine, and future organising should undertake a good faith effort to foreground Palestinian scholars and be BDS compliant. Stryker invited scholars to raise their hands if they were supportive of these statements of solidarity: a majority of the room immediately did so.
Finally, Stryker formally proposed the creation of a new International Trans Studies Association, as a context for trans studies scholars to organise for freedom. As the “largest, most diverse gathering of trans studies scholars to date”, she stated her belief that the conference had a mandate to make a decision on the creation of this new association. She proposed that this process begin by taking advantage of the international steering group assembled for the 2nd International Trans Studies Conference, with this group invited to create proposed bylaws for the new organisation, and all conference attendees invited to join as founding members and vote on the proposed bylaws. Stryker asked if the room was in favour of this process, and asked us to raise our hands if so: once again, there was an overwhelming expression of support.
And that was it!
I’m really grateful to everyone who has written to say how they have found this series of blog posts interesting or useful. I think it’s really important to share material from conferences with people who are unable to attend. I used to regularly livetweet, but this no longer feels like a productive form of engagement. Writing up my notes ended up taking a lot longer than anticipated, and the length of some of these posts has felt a bit unwieldy. It’s also a bit frustrating to be finishing off the series over a month after the conference ended! Still, it feels really important to have some kind of record.
I’m hoping to write a final post on the Trans Studies Conference, reflecting more broadly on my experiences and questions of accessibility and resourcing, possibly comparing and contrasting with the 2024 WPATH Symposium in Lisbon. Let’s see how I do!
I started writing this posted back in bonnie Scotland! Back to work, back to endless emails, back to doing my absolute best that all the masters dissertations are marked in good time. I finished it on an aeroplane to Lisbon, for my second major international event of September: the 2024 World Professional Association for Transgender Health Scientific Symposium, and am posting it from a conference centre in Lisbon.
As such, and as you might have noticed, I have slowed down with my writeup from the International Trans Studies Conference. Still, I have plenty more notes and reflections, and hope to continue writing these up over the next week or two.
My conference account left off halfway through the morning of the third day. After the sheer emotional onslaught of the session on political economy (no, really) I decided to slow the heck down and not rush off to the next talk. I went to the front desk where I managed to catch two of the conference organisers, Avery Everhart and Erique Zhang. I’ve known Avery and Eri online for years and long admired their work from afar, but we’d never previously met in person. I have really, really missed making these deeper human connections at conferences. Much as the organisers were clearly exhausted from firefighting technical and access issues to keep the conference running, it was wonderful to meet them and take time for a chat.
I therefore missed the first two papers from the next session I attended. This was a bit of pity given how amazing the rest of the session was, but self-care is important, and I regret nothing!
B{ending} Trans Game Studies
I don’t really do any work in game studies, so chose this session mostly because it seemed fun, and interesting. An opportunity to expand my horizons. This was the right choice – I had an incredible time.
I turned up partway through a presentation from Madison Schmalzer of Ringling College of Art and Design (USA), titled Circuit Bending, Trans Play, and the Death of Game(!) Schmalzer introduced circuit bending as a practice of “tinkering and seeing what happens”. Examples from her art, research, and teaching included rebuilding children’s keyboards, and messing with old Mario games to create something entirely new. Controls shifted, the sky changed colour, characters ran unexpectedly across the screen. Through the destruction and reconstruction of corporate entertainment products, students discovered entirely new modes of play.
Analysing this process, Schmalzer drew parallels between digital games and social constructs including gender and race. She argued that circuit bending raises important questions about digital products, such as: why does this game exist? whose interest does it serve? And finally: how might we “bend” other social systems in the same way that we might do with games?
Some possible responses to these questions were offered in the next paper: “We Can A̶l̶w̶a̶y̶s̶ Never Tell”: Giggling Faces, Gender Machines, And Un-Recognizing Play, by PS Berge of the University of Albert (Canada). Berge introduced the concept of “ludoarsony”, which variously refers to breaking, burning, or destroying a game (including technical or cultural rule sets), or to playing with fire, creating and playing through the act of destruction. Berge posited that ludoarsony, like play more generally, is a trans thing to do: “play and transness are of kin: both are transformational movements that weave in and out of rigid cultural and computational systems that they are ultimately ambivalent to”.
Berge’s paper drew on a number of case studies in which trans people play with the claim commonly made by transphobes that “we can always tell”: the notion that trans people are inherently clockable as such, that we are always reducible in behaviour and appearance to our sex assigned at birth. The first of these was Giggle for Girls, the now-defunct trans-exclusionary social networking app “for females” (recently central to the groundbreaking discrimination case Tickle vs Giggle…no, really).
Giggle’s verification system for female users relied on so-called gender-recognition technologies. Berge observed that on launch, Giggle was not simply criticised by trans people, but also played with. Examples included trans women testing the verification system (“I’m proud to announce that apparently I’m cis now. I’d like to thank Satan”), and revelling in negative reviews from cis women who were not recognised as such (e.g. “I can’t even access this app […] I was so looking forward to a female-only space, but now I just feel alienated. Thanks for that.”).
Further undermining the logic of “we can always tell”, Berge discussed the work of algorithmic artist Ada Ada Ada, showing us an example of a video in which the artist changes the response of facial recognition software in real time by pulling different expressions. Ada Ada Ada followed this up with “The Misgendering Machine”, an app available to anyone with a phone camera or webcam, which encourages people to play with how they are gendered by the machine.
Berge concluded by arguing that there is play in the unmaking, and to find play in the unplayable helps us find life in the unliveable: “we do not play in spite of the world being on fire – we play because the world is on fire”. Central to this is a project of mutual recognition: “we can never tell”, an acknowledgement of the ways in which we are all fundamentally unknowable, a promise not to rat each other out.
My horizons suitably expanded, I headed out to grab lunch.
Picturing Trans: Studies of Trans Visual Culture
In the afternoon I again wanted to attend a session that offered a different perspective to the material I normally encounter in my work on trans healthcare, both to expand my horizons and take something of a break from the slow creeping horror of my own area. So I want to a session on trans visual culture.
The first two talks offered radically different perspectives on trans people’s self-representation: one looked at self-portraits of trans bodies, and the other very intentionally looked at why we might avoid portraying our own bodies. The third talk then looked at how we might be represent and be represented by other trans people.
In Beyond Representation: Photographic Methods in Trans Myth-making, June Saunders of Washington State University (USA) offered a beautiful, poetic reflection on trans photography and representation that elides direct representations of our bodies. Saunders presented numerous images of landscapes, buildings, and everyday medical paraphernalia to accompany her talk. She encouraged us to be present in the moment without our devices, reflecting the themes of the presentation.
Sanders focused on how we might sit within and create photography that captures specific experiences and moments in time, without simply using this to produce commodifiable content. She examined the tension between the power of self-representation and exploration on the one hand, and the use of images in the service of surveillance and control on the other.
Ace Lehner of the University of Vermont (USA) looked instead at bodily self-portraiture in Transing Identity in Contemporary Photography: Zackary Drucker and Rhys Ernst’s Relationship. Noting that trans visual culture has played a crucial role in political representation and social change since the 1990s, Lehner looked at the “accidental” historic art project undertaken by Zackary Drucker and Rhys Ernst as they depicting their transition and relationship. Echoing Berge’s morning presentation on trans play, Lehner argued that trans visual culture can enable us to challenge dominant cultural logics that assume seeing is uncomplicated, and that we can easily read gender, sexuality, and race onto images.
Given the enormous number of contemporary visual transition diaries posted online by transmasculine people, it was interesting to hear Lehner argue for the importance of work by artists such as Drucker and Ernst in the 1990s, when transmasculine individuals were often ignored or erased in the media. Of course, as Lehner noted, transfeminine people have hardly benefited from historical media interest in bodies, which are sensationalised as objects of heightened sexualisation, and non-consensually aligned with dominant cultural ideologies.
The final presentation in this session was by AC Panella of Santa Rosa Junior College (USA), titled I Got 99 problems and Objects of Trans Memory Are Some of Them. Panella asked what we are teaching each other about what it means to be trans and “do” transness, especially given the limitations of existing trans archives. Said archives are typically derivative of lesbian and gay archives in their approach, and/or subsumed within wider LGBT collections, leading to misguided ideas about trans history. They can also contribute to US-dominated approaches to trans history, with celebrations of Pride (for instance) often marking Stonewall, rather than localised celebrations of trans uprising. These issues are compounded by the economic insecurities experienced by many trans people, with housing issues (for example) meaning individuals are less likely to hold on to items from their past. This spoke to a conversation I recently had with a fellow activist who lost much of her personal archive during a period of homelessness.
Panella outlined how these issues might be addressed through localised community projects, and the involvement of artists. The presentation included several examples of Latinx trans projects in Mexico and the west coast of the USA. They incorporated approaches including community storytelling through writing and arts workshops, intimate portraits of people in their homes, and memorial or celebratory pieces (e.g. fashion displays) based on the lives of community members that activists felt were important to remember. In this way, it is possible to create archival material which captures the complexity and nuance of local experiences, tying these both to cultural history and to contemporary struggles.
Transnationalizing Trans Studies: Building a Truly Global Field
The final session of the day was a plenary panel in the main conference hall. Titled “Transnationalizing Trans Studies”, it offered a refreshing alternative to the North American perspectives that dominated much of the conference, but also once again highlighted the limitations of the conference’s internationalism. We were meant to hear from a scholar-activist in Zambia – the only planned plenary speaker from Africa – but unfortunately she was unable to join us due to energy shortages. I truly hope future events can address this oversight: a matter addressed by the chair, Francisco Fernandez Romero (University of Buenos Aires, Argentina) in his introduction.
The panel therefore featured three speakers who responded to questions from Romero: Madi Day of Macquerie University (located in what they intentionally highlighted as the occupied territories named “Australia”), Alyosxa Tudor of the School of African and Oriental Studies, University of London (UK), and Michelle Ho of the National University of Singapore (Singapore).
The discussion opened with a question from Romero about what trans studies looks like across these contexts. Day began by explaining that, as an Indigenous scholar, they approach the field from an Indigenous studies perspective. They emphasised that Indigenous studies should not be understood as the study of Indigenous people, but rather as a critical examination of the colonised world. This approach understands settler colonialism as a global apparatus, with some Indigenous lands directly occupied (as with Australia), and others exporting their resources to the colonial centre (as Romero described earlier in the day with reference to Argentina). In this context, “colonialism is the condition of possibility”. Day therefore distinguished between white settler trans studies in Australia, and Indigenous trans studies. They spoke to the importance of drawing (appropriately and with due credit) on Indigenous approaches in trans studies, to better address the problem of material from the Global South being always used as data, and never as theory.
Tudor spoke to their context as an academic of Eastern European heritage living in the UK. They argued for a transnational approach to trans studies that goes beyond the “national” in understanding global-local connections, and embraces anti-nationalist principles, insisting that transnationalism is “not about all the small nations sitting down with the big ones for a nice chat!” This is important for interrogating discourses of Eastern European exclusion in trans studies: simply creating a series of national sub-fields is not an adequate solution. Relatedly, Tudor emphasised that a transnational trans studies cannot escape the current moment of genocide in Gaza, and must name the violence inflicted on the Palestinian people.
Ho discussed questions of multiple marginalisation. Citing the TSQ: Transgender Studies Quarterly special issue “Trans in Asia, Asia in Trans”, she observed that trans studies remains marginal in Asian studies, just as Asian experiences are marginal within in US-dominated trans studies. She also emphasised the difficulties of difficulty of translation in terms of both language and experience, with an enormous diversity of “trans” possibilities present across the Asian continent.
Romero followed these comments with questions that followed up on the topics of translation and transnationalism. Day argued that if trans studies is to be truly transnational, the goals and ambitions should be determined the global Southern majority. The problem in only calling on Indigenous knowledge when it’s directly relevant to Indigenous experiences is that you maintain a colonial viewpoint: if you are a white settler leading a research project, group, or institution and are not actively resisting settler colonialism, you are conducting a white settler project.
Day highlighted how shared experiences across Indigenous communities in different parts of the world have informed shared resistance and productive modes of thinking, and asked: “what would happen if we started thinking of transness as an identity rather than an identity?” But to be in a community, you need to act like a community. Community is non-extractive, and if you have more of something, you need to use it to help others.
Tudor returned to the question of nationalism. Contrasting with Day’s account of community, Tudor argued that nationalism rests on logics of opposition and competition, and resists complexity. In additional to critiquing white, Western nationalisms, they observed that decolonial, diasporic, and minoritised nationalisms also deserve scrutiny, as contemporary counter-hegemonies may become future hegemonies. That is to say: a people’s historic experiences of violence and oppression may not present future violence against others in the name of a new nation, as seen in the example of Israel. Tudor suggested that queer and trans studies might offer a vehicle to highlight the violence of nationalism, through challenging and deconstructing categories, from gender to nation. In this context is important that decolonialism is a mode of action, not a metaphor. Tudor noted they have used their platform as an academic speaker to highlight the growing death toll on Gaza, but this kind of speech act alone is insufficient: “it is clear none of my previous papers have saved a single life”
Ho focused especially on the topic of translation, exploring what might get lost through simply assuming that the language of one context might adequately explain another. She emphasised that to be adequately in conversation with a context, we need to learn their language and culture. This creates real problems for “international” publishing in the English language. Echoing Day’s comments earlier in the plenary, Ho noted the pressure to use Western theory to analyse Asian case studies, and described how a peer reviewer insisted that there were too many “non-English words” in her manuscript: the implication being, “can you do something to avoid alienating your largely US readership?”
Ho concluded by reflecting on the difficulties in attempting transnational approaches to trans studies in Singapore. What compromises are necessary in a very conservative society? She described the example of trying to get funding to bring in a trans studies scholar to speak at her institution, noting that the question is in part one of framing: “I could invite Jack Halberstam to come, and say ‘Jack Halberstam is an established scholar in cultural studies’”. However, given how Western-centric “transnational” scholarship is, this strategy is more effective with US academics than, for example, experts from India. Ho ended with two open questions for us to consider: if trans studies is effectively underground in a specific context, can it be considered trans studies? And how can Western scholars learn from people in these contexts?
The following Q&A session included some interesting reflections on the binary of Global North / Global South given the experiences of Indigenous people in settler-colonial nations. On this note, Day stated their appreciation for the Trans Studies Conference operating within established protocols for Indigenous engagement, for example through inviting Indigenous contributors to speak first: this could be seen bothin Kai Pyle’s opening statementson the first day of the event, and in the structure of this very plenary.
There is something about seeing your experiences accurately represented in research. This can be very emotional if you are used to seeing people like you ignored, erased, or otherwise grossly mispresented. Much like media representation, research representation can be powerful in putting a mirror to our experiences and suddenly making them a lot more real.
I dislike the vast overuse of the term “valid” in trans discourse, but there is something very important about being actively validated, about being seen, when the entirely of society feels like it’s set up to deny or gaslight you. It’s a consciousness-raising moment, in which you become capable of truly acknowledging or naming what is happening to you. It is meaningful and authentic and it enables action. But it is also very painful.
As a trans health researcher, I think I’ve developed a pretty thick skin. I see a huge amount of bad trans health research, built on cis ignorance and a fundamental inability to engage with the reality of our lives. I also see growing amounts of painfully real research from researchers who are engaging with care. For better and for worse, I feel I’ve learned to carefully manage my emotions and let all of this wash over me, in order to engage consistently and “professionally”.
But on Thursday morning, a series of presentations made me cry.
Global Struggles, Local Solutions: Transgender Perspectives on Economics and Welfare
The morning began with doughnuts, piled high in the reception area of the conference, a very extravagant seeming American breakfast. From there I headed to the first session of the day, which explored trans political economy. This might seem like the dryest topic imaginable, but for me it gets right to the core of how systemic transphobia and cisgenderism operate, how we feel about that, and what we might do about it.
The study of political economy is concerned with how economic systems interface with social and political systems, and vice-versa. The first paper in this session, by Yukari Ishii of Sophia University (Japan), looked at homeless trans people’s access to welfare systems. In Reasons Underlying Gender-diverse Individuals’ Need for Public Social Welfare Support in Japan, Ishii reported on findings from the 2009-2020 consultation records of Moyai, a non-profit voluntary sector welfare provider, plus interviews with service users.
Ishii’s paper mapped in detail how trans people find themselves accessing welfare systems after being failed by heteronormative and cisnormative systems throughout their lives. She described trans people being rejected by their parents, dropping out from school due to the hostility of the heavily gendered environment, which limited their formal educational attainment. Participants in her research struggled to find work, or were otherwise fired for being trans. More tolerant work environments either required skills or an education background that trans people were less likely to have, or were deeply insecure, as in the case of sex work. Trans people who struggled to hold down a job also struggled to find places to live, with many sleeping at friend’s houses, in Internet cafes, or in the streets.
Ishii’s research showed up vulnerability is created through structurally embedded cisgenderism, impacting people from families to schools to workplaces and even to apparent sites of last resort; for example, she described how Internet cafes did not allow trans women to stay overnight if they were sex workers. She further noted that the consultation records at Moyai were limited where consultants didn’t have a lot of knowledge about queer people, or didn’t know what questions to ask about (for example) family violence. She concluded by recommending that welfare professionals gain knowledge of gender and queer issues, to ensure they are best placed to provide advice and support to service users, and keep better records for improving long-term understanding of the problems faced.
The next paper similarly traced the deep context of economic disadvantage, this time looking to history for a deeper context. In Trans-cending Barriers to QTPOC Labor in the South, Anthony Belotti of Virginia Commonwealth University (USA) focused on the US South’s historical legal landscape, linking this to the region’s racism, homophobia, and transphobia.
Belotti argued that “the history of the South has created an environment where QTPOC (queer and trans people of colour) do not have equal access to labour opportunities and class mobility”. Various legislation effectively criminalised queer, trans, and Black existence, including the Jim Crow laws, “decency” laws which banned wearing clothes not associated with sex assigned at birth, and anti-union “right to work” laws. Belotti argued that while there is relatively little archival material on QTPOC experiences in the South, these laws provide an important insight into people’s experiences, especially given the existence of legislation such as the decency laws implies a perceived need for them from authorities. The concrete impact of all this was that QTPOC had difficulties finding and keeping legal employment.
By the time Dan Irving presented, I will admit I was already feeling pretty vulnerable. In Ishii and Belotti’s excellent papers, I heard about contexts both very different to the UK, and remarkably similar. Beyond the broad importance of their findings, I recognised in their accounts the experiences of so many of my friends and colleagues – a meaningful and painful experience that underpins so much of my engagement with good work in trans studies.
Irving, of Carleton University (Canada) presented a paper titled Sensational Disruptions: Affective Economic Justice at Work. Building on his previous work on trans political economy, this presentation reported on findings from two large qualitative research projects on unemployment and underemployment among trans and non-binary people in Canada, conducted in 2012-16 and 2020-24.
Irving’s paper focused on exploring one anticipated finding from these projects in depth: the “I can’t put my finger on it” feeling. This theme involved participants encountering difficulties in the workplace or in attempting to land work, but finding it hard to articulate why they couldn’t get the job, or had hours reduced, or were laid off, even when appropriately skilled – or overqualified. There was something about getting through the door and finding the vibe was off. These experiences were especially likely to be detailed by trans people from racialised minorities, and/or trans women.
I immediately recognised what Irving was describing. How could I not? He had just described years of my experiences in the workplace as a trans woman. And of course, this isn’t really a new insight: the problems he named have been discussed in feminist literature for decades (especially Black feminist and womanist literature), and indeed within the consciousness-raising group I joined shortly after moving to Glasgow. These findings also related to the phenomenon reported by people from many marginalised groups, whereby we always have to be the very best to succeed in a basic manner in the workplace.
What was most useful about Irving’s paper, however, was his theorising of the phenomenon. In a manner that resonated with Nat Raha’s comments on the second day of the conference, Irving turned to affect theory (explanations that centre feeling and emotion) to explore what is happening to us in the workplace.
Irving described how trans people (especially racialised minorities, and women) often find ourselves constantly doing the additional work of ensuring that managers, co-workers, and customers feel comfortable with us. This causes a “sensate disruption” in our lives, shaped by the “corrosive impact of fear, repulsion, anger on the part of cisnormative employers, co-workers and customers and the violent impacts of rage, depression, exhaustion on trans jobseekers and workers”. Even worse, there are few outlets for these emotions: neoliberal discourses of personal responsibility mean that feelings are expected to be quarantined within the body of the (marginalised) worker, for example through us taking responsibility for our transitions and bodies and carefully managing our relations with others.
It was at this point that I started to cry.
I feel so, so tired and alienated in my work, all the time. I have some amazing colleagues and students, but I am still working in a system where I can feel myself being discriminated against while also finding it hard to always articulate the exact ways in which it happens. I am tired of being advised to refocus my energies in the workplace even as an eliminationist movement works against trans existence. I am tired of my research being erased or dismissed, I am tired of being asked to meetings where I am ignored, I am tired of being asked how the institution can best protect me, I am tired of being told that my failed grant applications are the “most impressive unfunded bid” that people have ever seen. I am tired of having little language for these experiences, and of pushing my feelings down every day.
I am tired of seeing as much, and far far worse, happen all the time to my trans colleagues and friends.
Responding to these findings, Irving asked: “how do we begin to grapple with the ‘affective byproducts’ of post-industrial demands for affective labour?” How do we reckon with the unsayable in our felt experiences? And quoting Deborah Gould, “what kind of political context do we need to build that actually listens to what many people are feeling and that cares about people’s disappointment, despair and furies?”
Drawing on the work of Hil Malatino, Irving proposed “infrapolitics” (low-profile, informal, undeclared forms of resistance) and community care as a basis from which to build solutions. Drawing from participant narratives, he argued that this can include political acts of resistance that are “not on the oppressor’s radar”: examples included zines and phone lines distributing information among workers and applicants, building community connections, and forms of entertainment and commentary such as comic strips. Like Ishii, Irving also highlighted the ways in which trans people effectively provide welfare services for one another, for example by providing beds or housing for homeless community members. What this all amounts to are forms of anti-capitalist resistance that amount to a collective recognition and addressing of the problem.
Sticker spotted at the conference. An example of infrapolitical resistance.
The session concluded with another extremely powerful and nuanced presentation, from Pato Laterra of the Interdisciplinary Centre for the Study of Public Policies, and Francisco Fernandez Romero of the University of Buenos Aires (both Argentina), titled A Trans Political Economy from Elsewhere: Reflections from Argentina. Like the other presenters, Laterra and Romero sought to use the concept of political economy to understand how trans lives are embedded in existing political structures, and propose alternatives for survival. They emphasised that in Latin American contexts, there is a strong tradition of research on travesti and trans people’s living conditions, with travesti-trans politics prioritising mutual support and resource distribution. It is within this context that they looked at implementation and impact the travesti-trans labour quota within Argentina’s public sector.
The travesti-trans labour quota is a form of reparative politics, in which 1% of federal jobs are reserved for trans people. This policy represents a response to the deep, systematic discrimination faced by travesti and trans people in Argentina, which reflects that reported from Japan, the USA, and Canada through the rest of the session. It was implemented in response to radical political demands from campaigners, with the presenters sharing a photo of a flag featuring a slogan they translated as “quota and reparation, we want redistribution”.
To understand how effective the travesti-trans labour quota is in practice, Lattera and Romero insisted on a rethinking of trans political economy, going beyond just thinking of trans people as workers or consumers. They wished to emphasise:
everyday reproductive and care relationships, in terms of that which sustains life beyond income or the market;
social policies that enable or do not enable certain lives, especially for people with an insecure relationship to the market;
situated perspectives, for example through acknowledging how labour (and theory!) from the Global South is extracted by the North.
Lattera and Romero argued that the labour quota partially subverts trend towards assimilation regarding trans people’s inclusion in labour markets. This is because the quota aims to achieve economic redistribution, and positions access to work as a human right. Moreover, it supports the employment of the “least employable”, i.e. trans people who are more likely to be without educational qualifications, or have a police record. In this way, it offers a response to many of the issues outlined by the previous presenters, and an alternative to typical liberal capitalist logics that involve capturing the economic benefits of trans labour.
However, as one intervention within a wider network of unequal systems, the labour quota has significant limitations. Lattera and Romero noted that the “right to work” reifies labour normativity: that is, it upholds the idea that our value as human beings is dependent on being able to have paid jobs, and that paid work is more important than unpaid care work, community work, or domestic labour. Moreover, in practice, the trans people actually hired under the labour quota are most often the most privileged, being predominantly young, white, and highly educated; and once in role, they face a significant pressure to assimilate.
Lattera and Romero urged against any simplistic reading of the labour quota’s benefits or drawbacks, in a manner that forced me to reflect on my aforementioned feelings that “other trans people have it worse”. The “more privileged” trans people hired under the labour quota still face significant disadvantage in their lives. For many, this is their first job, and it is not well-paid. Moreover, those who do tend to land these roles within the public sector tend to regard it as a job they are gaining not (just) for themselves, but for their wider community. The introduction of the quota has also resulted in increased trans labour organising and trade unionism, including increased collaboration between trans and cis colleagues in service of their shared interests. This has been especially important given the mass firings of public sector workers by President Javier Milei since his election in 2023.
The presenters concluded by arguing that trans people’s concerns should be understood within transnational political-economic processes. For example the recent firing of trans workers is a part of wider processes of extraction, in which the Argentinian government is “giving away our wealth to the Global North”. At the same time, there are always lessons to be learned from different parts of the world, so long as we properly acknowledge where these ideas come from and show care in doing so. The Argentinian labour movement invites us to imagine other ways of trans participation in the economy, beyond capitalist productivity.
Game studies, visual culture, and transnationalising trans studies
I’ve had a lot to say about trans political economy, and I have had a very specific story to tell about how my own experiences intersect with what I learned. At the same time, this was just the first session I attended on the third day of the Trans Studies Conference. I’ve therefore decided to split my notes on this day across more than one post. I have yet to write about playing games with Giggle, trans photography and archives, or resisting settler colonialism – and that’s before we get onto Day 4. Watch this space!
Young trans people have been leading an incredible protest at Wellington House, the London headquarters of NHS England. They have been holding space on a ledge of the front facade since London Pride on Saturday 29 June.
The protesters will be coming down today (Tuesday 2 July) and have called for supporters in London to join them at a rally from 4pm.
The action powerfully highlights the repeated failure of UK politicians, the mainstream media, and NHS bodies to truly listen to young trans people about their experiences and needs. This is perhaps most powerfully seen in the Cass Review, which has systematically excluded expertise and evidence from trans people in formulating its recommendations, and in trans healthcare bans implemented for under-18s in England in Scotland. Meanwhile, the Labour party are promising to uphold these bans and implement a range of deeplytransphobicpoliciesshould they win the election on 4 July.
These concerns are powerfully highlights by the protesters themselves. InDiva, a 17 year old activist explains:
“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.
In every other way I am trusted when I tell people what I want to do with my life. But not now. There is so much real anger out there and we hope our actions will encourage others to fight for a voice, and the healthcare and dignity that we are currently denied.”
“We are staging this protest to remind politicians and voters that we’re real kids, not just political talking points. We may not have a vote, but it is our lives that are at stake. Gender-affirming healthcare is a matter of life and death for us and we hope our actions will bring awareness to this fact and encourage others to fight for the healthcare and dignity we are so shamefully denied.”
As a former youth activist working in this field for almost two years now, I am hugely heartened and inspired by this powerful protest. In the face of institutionalised violence and silencing, young trans people are seizing the narrative. It is up to us adults to listen, learn, and fight alongside them.
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 @transprotestglasgowfor the video.
Readers seeking more detailed evidence and academic critiques may find my previous blog post helpful: What’s wrong with the Cass Review?
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
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. ↩︎
“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. ↩︎
“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). ↩︎
Although in practice, trans people are often also turned away from mental health services due to “trans broken arm syndrome“. ↩︎
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. ↩︎
“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) ↩︎
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”. ↩︎
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. ↩︎
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). ↩︎
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. ↩︎
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[.]” ↩︎
p.70, used to evidence the activities of GIDS’ research team at a WPATH conference. They could have instead cited the conference website. ↩︎
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.” ↩︎
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.” ↩︎
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 primarily 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;
protests and demonstrations.
I am keeping this post updated with new material. However, whilst there is a lot here, this is not an exhaustive collection. There are now so many published critiques of the Cass Review that I do not have the capacity to track everything. I stick here to material I have (a) actually found and (b) actually read. Additionally, I have focused on written commentary, but there is also a growing number of good videos and podcasts on the topic.
“The Cass Review has been extensively critiqued by healthcare professionals, scholars, service users and trans communities, and is considered an exemplar in policy-based evidence-making […] Parent/carers felt the model of care being offered by the new CYPGS was conversive, with a parent describing the gender clinic approach post Cass Review as ‘conversion therapy under a different name‘”.
“The first sentence of the introduction to the final report (Cass Review, 2024) states ‘this Review is not about defining what it means to be trans, nor is it about undermining the validity of trans identities, challenging the right of people to express themselves, or rolling back on people’s rights to healthcare’ (p. 12). In reality, the Review achieved all of these things and more.”
“The Cass Review and its impact is significant for two reasons. First, it 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. Second, the Review’s impacts are not limited to the United Kingdom.”
“The consequences of this ban [on puberty blockers, post-Cass] on trans and non-binary children and young people are analysed revealing very serious adverse effects, less than a year after its imposition, including sharply declining mental health, increased depression, social isolation, anxiety, stress, self-harm, school avoidance and suicide ideation.” […]
“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[.]”
“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[.]”
“The lead author had no expertise in the treatment of or research into gender dysphoria in children and adolescents, and individuals with lived experience of being transgender had limited input into the process. This contravenes best practices for evidence synthesis and guideline development, which call for appropriate subject-matter expertise and meaningful accountability to stakeholders to mitigate bias and strengthen validity. By analogy, a review of cisgender women’s health that overtly excluded clinicians or researchers specialising in the field and rebuffed input from cisgender women themselves would rightly be regarded as biased, uninformed and fundamentally flawed.”
“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.”
~
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.”
~
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.”
~
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.”
~
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.’”
“The Mermaids UK submitted their recommendations for consideration of what the queer/trans youth would prefer and/or want and this article explains further what those may look like one year on. The main issue was that the Cass review had ignored their voices by not considering the Mermaids’ recommendations […] Recommendations not fully addressed were the following […] Comprehensive Support Services […] Inclusion of Trans Voices and Expertise […] Affirmative and Respectful Care”.
Ruth’s note: this article is written by a therapist who facilitated structured consultations with young trans people in Mermaids on behalf of the Cass Review. Reflecting wider issues with the Review, the article contains some significant ethical problems – includingthat claim that the article does not “count” as research, and therefore did not require any formal ethics review. However, it also provides an important account of how the voices of young people theoretically consulted for the Cass Review were actively ignored.
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.“
“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.
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 aconference 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.
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.
I’m really happy to announce that an article I co-authored, “Transnormativity in the Psy Disciplines: Constructing Pathology in the Diagnostic and Statistical Manual and Standards of Care”, has been reprinted in the Palgrave Handbook of Power, Gender, and Psychology.
Originally published in American Psychologist in 2019, this was among the first of many articles written collaboratively with my colleagues in the Trans Pregnancy Projectteam: Damien W Riggs, Carla Pfeffer, Sally Hines, Francis Ray White, and Elisabetta Ruspini. I hope that through its inclusion in this new handbook on theories of gender and power in feminist psychology, this slightly updated essay will reach new readers and provide helpful context on the construction of sex/gender norms through classification and diagnosis.
As I explained on its original publication, in this piece “we examine how the interests of cisgender clinicians and trans patients have variously been opposed and entwined, and contextualise this in relation to wider structures of racism, sexism, colonialism, and binary thinking around sex and gender. We focus especially on how guidance for diagnosing trans people and managing trans healthcare has been contested across various versions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (the DSM) and the International Harry Benjamin Gender Dysphoria Association (HBIGDA, later WPATH) Standards of Care.”
Dr Ruth Pearce 