hormone therapy

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Open letter to Yvette Cooper on dangerously flawed NHS research

In May this year I was one of 85 expert signatories to an open letter to James Palmer, NHS England’s National Medical Director for Specialised Services. The letter, organised by Trans Actual, raised serious concerns about the NHS evidence reviews of hormone therapy for trans youth, the subsequent prescribing policy (i.e. a ban on NHS hormone therapy for young trans people aged under 18), and an associated public consultation.

Three months later, Palmer responded. Unfortunately, he dismissed our concerns, and outright ignored most of the evidence we presented regarding the methodological and ethical flaws in the NHS England evidence reviews.

At this stage, we have no confidence in receiving an adequate response from Palmer. My personal view is that both Palmer and NHS England as an organisation have chosen to prioritise political convenience over both good research practice and patient safety (there is a longer history to this too). Following a consultation with signatories, Trans Actual therefore took the decision to escalate the matter to the current Secretary of State for Health and Social Care, Yvette Cooper.

I have reproduced the letter below – you can also read Trans Actual’s press release and the fully-referenced, signed version sent to Cooper here.

Dear Secretary of State,

We write regarding the series of evidence reviews commissioned by NHS England into masculinising and feminising (MAF) hormones for under-18s with gender dysphoria. Based on these reviews, NHS England has consulted on a policy proposal that would make these hormones for under-18s no longer part of the clinical commissioning policy.

In May 2026, a joint letter to Professor James Palmer was signed by 85 clinicians, researchers and academics raising significant ethical, methodological, and procedural concerns with these evidence reviews and the resulting policy proposal.

In August 2026, Professor Palmer responded to our letter (attached), but a number of concerns raised were not addressed to our satisfaction.

We now write to you directly to highlight the significant issues that remain, namely: the lack of clear rationale for these reviews, the significant methodological issues and risk of bias that is evident, and lack of any plan to monitor the impact of this denial of healthcare on young trans people.

1. Lack of clear rationale

Palmer was asked to clarify the exact rationale for these 2025 under-18 evidence reviews, given that NHS England had already updated the relevant clinical commissioning policy in 2024 in response to the findings (Recommendation 8) of the Cass Review of Gender Identity Services for Children and Young People, which included the systematic evidence review of hormones for under-18s conducted by the University of York.

In his response, Palmer explained that evidence reviews are commissioned as part of standard policy development, but provided no indication of any specific impetus for reviewing this policy just one year after it had already been updated.

Following a related FOI request to your own Department of Health and Social Care (FOI-1720493), we have determined that the most likely trigger for these under-18 reviews was in fact the out-of-scope and unvalidated concerns regarding adult services raised by Baroness Cass in her May 2024 letter to John Stewart and Professor James Palmer (see also para 19.34 of the Final Cass Review).

On the basis of these unevidenced concerns, John Stewart and James Palmer decided to “define the role of gender affirming hormones through the development of a new evidence based national clinical policy which will cover all people over the age of 16.”

We note that this work was launched outside of the already-commissioned Levy Review of adult services, which did not report any such concerns regarding hormone prescribing.

In the course of developing the scope of this “all ages” national clinical policy, the Policy Working Group “deemed [it] necessary” in April 2025 to split the evidence reviews into separate children and young people (CYP) and adult policy documents, due to “the significant variation in dosage of MAF between adult and CYP populations”.

At this point, it should have been recognised that:

  • a comprehensive evidence review of CYP hormones had already been carried out as part of the Cass Review;
  • NHS England had already produced an updated CYP hormones clinical commissioning policy following that Review;
  • an ongoing living evidence review into under-18 hormones had been commissioned by NHS England and was already funded and underway.

Instead, NHS England embarked on a redundant and duplicative review of the clinical commissioning policy for MAF hormones in under-18s, overriding and ignoring both the findings and original recommendations of the Cass Review, its own 2024 CYP policy update, and the funded EPPI living review.

We are extremely concerned that Palmer was not able to give us a clear answer as to the impetus for these 2025 under-18s reviews, and that as a result of this confusion, NHS England has spent valuable time and resources duplicating and overriding work it had already commissioned and / or completed.

2. Methodological issues and risk of bias

We are further alarmed by multiple methodological decisions taken in the commissioning of the under-18s evidence reviews.

In particular, we raised in our initial letter our concerns with the decision – taken not by the independent researchers, but the policy working group – to split what is effectively two interventions in under-18s (masculinising and feminising hormones) and at most two treatment populations (those seeking masculinisation and those seeking feminisation) into 10 separate PICOs.

While we agree with the statement in Palmer’s response that Cochrane advocates for a balance between overly-narrow and overly-broad search criteria when conducting evidence reviews, Cochrane also specifically emphasises (2.5.3) that review criteria may require modification in response to initial search results, particularly when dealing with sparse data:

“The ability to address the review questions will depend on the maturity and validity of the evidence base. When few studies are identified, there will be limited opportunity to address the question through an informative synthesis. In anticipation of this scenario, review authors may build contingencies into their protocol analysis plan that specify grouping (any or multiple) PICO elements at a broader level; thus potentially enabling synthesis of a larger number of studies.”

In our view, the fact that 6 out of the 10 PICOs returned zero (0) relevant studies should have been a strong indicator that the PICOs needed to be reconsidered, and that the initial protocols had erred far too far in the direction of “splitting”.

We also note that Cochrane differentiates between (2.3.1) review PICOs, and PICOs for comparisons between interventions or groups. NHS England appears to have entirely misunderstood or ignored this distinction.

Rather than beginning with one review PICO that would naturally be broad in scope, NHS England began with ten different PICOs already limited to specific sub-treatments (masculinising vs feminising, with or without concurrent GnRH analogues) and sub-populations (male, female, non-binary) – yet we note that NHS England has not generated 10 different clinical commissioning policies, only one.

This confirms that NHS England should have commissioned a far broader initial review PICO reflecting the actual review question — namely the safety and clinical effectiveness of MAF hormones for under-18s. Instead it appears that NHS England started with 10 different review PICOs, six of which resulted in zero studies being found due to their extremely narrow scope.

This leads on to one of the most unjustifiable methodological decisions made by NHS England in these evidence reviews.

Professor Palmer’s reply to us confirms:

“The use of GnRH analogues in this cohort is not routinely commissioned in England; therefore, any hormone regimen that could be commissioned cannot be based upon evidence of people who have already been treated with GnRH analogues because the treatment effects of masculinising or feminising medicines may be different for those who have received previous treatment with
GnRH analogues.”

Palmer uses the same justification to explain why dozens of studies that were included in the Cass-commissioned University of York evidence reviews were excluded from NHS England’s 2025 evidence reviews.

The law criminalising access to puberty blockers in England has been used by NHS England as a reason to exclude from its evidence reviews any and all international studies of masculinising and feminising hormones in which patients also received this treatment at any point prior.

This is despite the fact that puberty blockers followed by gender-affirming hormones has been a standard protocol globally for at least three decades, and as Professor Palmer himself admits: “many study populations include those who have received puberty suppression.”

We also note that, according to the March 2025 meeting minutes for the Policy Working Group, “Multiple members shared concerns raised of only having masculinising and feminising medicines (MAF) rather than the usual PSH [puberty suppressing hormones].” These concerns were seemingly overruled.

Adopting this bizarre exclusion criterion, based entirely on NHS England’s own unique and controversial policy position, inevitably led to the finding that there was a “lack of evidence” for masculinising and feminising hormones for under-18s, because so many studies were excluded.

All of this contributes to the exaggerated conclusion that there is an extreme lack of evidence regarding the use of MAF hormones in under-18s. This overstated scarcity has then been leveraged by NHS England to advocate for the removal of this aspect of gender-affirming care.

3. The appropriate response to “lack of evidence.”

Even setting aside the inconsistent rationale and significant methodological flaws we have highlighted above, there is the even more critical issue of how the purported “lack of evidence” is being used to justify the outright denial of care to trans people.

According to meeting minutes from 22nd January 2025, members of the Policy Working Group were assured that “in the absence of evidence, it is possible for specific policy areas to be informed by evidence-based decisions.” Despite this assurance, the proposed withdrawal of under-18 hormones appears to have been based solely on “absence of evidence” and, further, did not follow best practice approaches to evidence-based decision making.

We highlight statements from the BMA’s evaluation of the Cass Review regarding how evidential uncertainty is interpreted and actioned. While their points are in reference to the provision of puberty blockers, we believe they apply equally, if not more so, to the provision of under-18 hormones:

“The evidence base is limited and uncertain, with signals of both benefit and harm … A precautionary approach is consistent with this uncertainty. However, precaution in medicine typically involves risk mitigation alongside maintenance of care, rather than withdrawal of … treatment. … Alternative approaches (e.g. continued access with safeguards) are also consistent with the same evidence base.”

Instead of the precautionary approach and continued access originally recommended by Cass and adopted by NHS England on the basis of robust research, NHS England have now – for no good reason – overridden this, and are once again proposing a blanket withdrawal of treatment for trans people.

We also note that they are proposing to do so before any plans have been offered to monitor or mitigate the impact of treatment withdrawal, or develop any alternative systems of care.

4. Impacts of Treatment Withdrawal

In response to our concerns about the impact of treatment withdrawal, Palmer’s reply takes no account of patients currently on waiting lists or planning to seek referral to gender services in the hope or expectation that this might provide access to gender-affirming hormones.

As NHS England’s own Equality and Health Equalities Impact Assessment for this policy update makes clear:

“Patients who are already under the care of the NHS Children and Young People’s Gender Service and who have previously been advised that they would be referred for consideration of MAF hormones – but whose eligibility has yet to be clinically determined under the current policy – would no longer be eligible. This would mean that an existing aspiration for treatment will no longer be available for some individuals.”

The EIA also states that:

“Some stakeholder groups have previously suggested that withholding MAF hormones will lead to an increase in emotional and psychological distress, leading to risk-taking behaviour amongst children and adolescents.”

We remain extremely concerned about NHS England’s lack of articulated plans for monitoring the effect and impact of the proposed withdrawal of MAF hormones on young trans people.

Instead they have made the bizarre claim that “adoption of the policy [removing access to hormones] would in itself be a risk mitigation measure” “because of a lack of sufficient evidence relating to the safety and clinical effectiveness of MAF hormones for children and young people with gender dysphoria.”

In other words, without evidence, NHS England has adopted the blanket assumption that hormone treatments for under-18s are harmful, and therefore that the very act of denying this care reduces “risk”.

5. PATHWAYS Trial

We also note that if the decision is made to withdraw gender affirming hormones for under 18s from routine clinical commissioning, this will inevitably raise significant issues for the PATHWAYS (puberty blocker) research trial that is already underway.

The inability for young transgender patients to transfer onto cross-sex hormones with a reasonable time scale after beginning puberty blockers has already been a significant question raised in discussions of the ethical viability of this trial.

To date, we have been given no assurances as to how these issues will be addressed.

6. Expert statements

On reading Palmer’s response to our letter, Simona Giordano, a Professor of Bioethics at University of Manchester Law School, responded:

“One of the major concerns raised in our letter was that NHS England adopted review criteria that excluded a substantial proportion of the existing literature. In doing so, it risks repeating a longstanding methodological error in this field: attempting to separate the effects of puberty suppression and gender-affirming hormones as though they were entirely distinct interventions. In practice, many young people received these treatments sequentially as part of a single clinical pathway. This was especially true in England, where treatment with GnRH analogues was typically a prerequisite for access to masculinising or feminising hormones. Excluding studies involving such patients removes a large and clinically important part of the evidence base and may create a misleading impression about the amount of evidence available.”

Simona notes that Palmer’s response “does not adequately engage with several of the substantive concerns raised in the original clinicians’ and researchers’ letter, particularly those regarding the rationale for commissioning a further evidence review, the methodological choices underpinning the review process, and the implications of those methodological decisions for the evidence base considered.”

Chris Noone, a lecturer at the University of Galway who also read Palmer’s response, said:

“Guidance development and evidence reviews in Poland, France, Germany, and the Netherlands have all concluded that Gender Affirming Hormones are safe and effective as part of the care provided by gender services for young people. Furthermore, a recent paper in The Lancet (Doyle & de Vries, 2026) that considers the 13 systematic reviews that exist on this topic concludes that ‘gender-affirming medical treatment for adolescents does what it is intended to do—it shapes physical gender presentation in line with the affirmed gender of the adolescent. Research also indicates that gender-affirming medical treatment for adolescents is effective in terms of stabilising and improving the primary psychological target: gender incongruence (or gender dysphoria)’.”

He concludes that “the withdrawal of this intervention (1) does not follow from the existing evidence, and (2) does not consider the evidence on the risks of withdrawing this intervention.”

7. Conclusion

Our fundamental concern is that the provision of trans healthcare, including healthcare for under-18s, continues to come under immense external pressure from anti-trans actors, as well as being influenced by individuals within public institutions who approach policy and evidence-gathering from the presumption that gender-affirming care is inherently harmful.

In light of the above, we are calling on you as Secretary of State to:

  1. Meet urgently with James Palmer to seek answers to the unresolved ethical and methodological concerns raised in this and our initial letter, and ensure that these concerns are adequately addressed before any proposed change to the provision of MAF hormones for under-18s is finalised.
  2. Meet with trans healthcare clinicians and researchers and work with NHSE to ensure that future commissioning policy changes resulting from evidence reviews – like the forthcoming evidence reviews into MAF hormones for adults – are informed by a high respect for the expertise of clinicians, the autonomy of patients to seek care that reflects their goals and preferences, and a recognition of the risk of harm to trans patients of denying gender-affirming care.

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Open letter to NHS Director for Specialised Services on trans youth hormone ban

I am one of the 85 signatories to an open letter to James Palmer, NHS England’s National Medical Director for Specialised Services. We are raising serious concerns about the recent NHS evidence reviews of hormone therapy for trans youth, and subsequent prescribing policy and public consultation.

The letter has been published and sent to Palmer by Trans Actual – you can read more about it on their site here. In my signature, I note that I was a 2023 recipient of the NHS England LGBT+ Advisor Award. Unfortunately, in subsequent years, NHS policy on LGBT+ healthcare seems increasingly shaped by ideology and political pressure, rather than patient experience, expert advice, and evidence. In meetings I attended with Palmer in the early 2020s, I personally heard him share various forms of disinformation about young trans people, such as the factually inaccurate claim that recent cohorts of adolescents presenting with gender dysphoria represent a distinct population from young people referred to the same clinics in earlier years.

For a longer and more detailed critique of the NHS evidence reviews, see this excellent analysis by Kim Hipwell: A Medical Mess: An Analysis Of The NHS’s Proposal To Ban Hormone Therapy For Trans Youth.

The public consultation is open until 7 June, and you can submit a response here.

Dear James Palmer,

We are a group of clinicians, researchers, and academics working in gender care, paediatrics, and related fields of healthcare, medicine, and science.

We are writing to lay out our serious concerns with NHS England’s recently-published evidence reviews into the use of gender-affirming hormone therapy (GAHT) by children and adolescents.


1. Lack of Clear Rationale

The Cass Independent Review previously commissioned a systematic evidence review into GAHT for under-18s.

Based on this peer-reviewed and published analysis, Dr. Cass recommended that “NHS England should review the policy on masculinising/feminising hormones. The option to provide masculinising/feminising hormones from age 16 is available, but the Review would recommend extreme caution.”

In 2024, NHS England reviewed and updated their GAHT policy accordingly.

A “living systematic review” – also recommended by Dr. Cass – is now underway, to consolidate the evidence base and keep it up-to-date. This work is being conducted by EPPI-Centre and others, funded by the National Health and Care Research Institute (NIHR), and includes an ongoing review of evidence for GAHT for under-18s.

Therefore, it remains entirely unclear why – having previously wholeheartedly accepted the Cass Report – NHS England has now launched a separate evidence review that was never recommended by Dr. Cass and which duplicates other research already commissioned and underway.


2. Lack of Peer Review

None of the NHS England evidence reviews have been peer reviewed or written to meet publication standards. Instead, NHS England released the reviews only as part of a public consultation process and has asked the general public to “check that draft policies are well evidenced” and to determine whether “all of the relevant evidence [has] been taken into account”.

Consultation is not a substitute for formal academic review, and risks conflating technical evaluation with public opinion.


3. Methodological Limitations and Risk of Bias

Rather than address a single, clinically meaningful research question, NHS England subdivided the GAHT for under-18s evidence review into 10 separate and extremely narrow PICOs (population, intervention, comparison and outcome search parameters).

We have confirmed that this methodological decision was made by NHS England’s “Policy Working Group”, prior to instructing the “independent” researchers, Solutions for Public Health (SPH).

This methodological approach explicitly goes against the gold-standard guidance outlined in the Cochrane Handbook, which cautions that fragmentation of PICOs is likely to result in “sparse” evidence and “could be chosen by review authors to produce a desired result.”

As a result of these overly-narrow search parameters, the researchers had to exclude some of the most significant studies on gender-affirming care for young people, such as Chen et al., 2023, the largest NIH-funded prospective study of trans youth ever conducted.

Ultimately, the researchers could find only 11 eligible studies across all 10 PICOs, with 0 (zero) studies found for 6 of the 10 reviews. In contrast, the University of York evidence review commissioned by Dr Cass found 53 studies, 34 of which were assessed as moderate- or high-quality.

As an example, studies were deemed “out of scope” if participants had received GnRH analogues in the context of puberty suppression prior to receiving gender-affirming hormones (despite the fact that this was the standard treatment protocol internationally for many years, including in the UK).

According to the published reviews, as a result of this methodological decision alone at least 38 studies were excluded that would otherwise have been eligible (and potentially many more at title/abstract stage). These studies could, at the very least, have provided information on the risk profile of GAHT, a factor which NHS England claims to be central to their policy decision making.

NHS England has published no rationale at all for this – and other– methodological decisions. In response to an FOI request, NHS England indicated that studies involving GnRHa puberty suppression “cannot be included” in the PICOs because of “legal issues”, an “ongoing research trial in this area” and “lack of new evidence” – reasons that we find scientifically unsound.

Additionally, in contexts where limited evidence is available for a paediatric intervention, it would be typical for researchers to consider extrapolating data from research into adults, something that NHS England again chose not to do.

In effect, NHS England has adopted a methodological approach that predictably minimises the available evidence base, then cites this manufactured scarcity as a justification for restrictive policy conclusions.


4. Misreporting and Misapplication of Findings

Especially in paediatrics, clinical policy and decision-making is commonly based on evidence considered limited and/or “low-quality” as recognised under the GRADE system. There is therefore no reason why the purported lack of evidence reported in these reviews should automatically lead to the policy position that gender-affirming hormones are so unsafe and/or ineffective for 16- and 17 year olds that they must be immediately withdrawn.

Even when looking only at the 11 studies included in this NHS England evidence review, we believe the overall pattern of evidence suggests that the benefits of GAHT for under-18s outweigh any harms. We believe this is also the case in the University of York review.

We have also found that at least one of the studies included in the SPH reviews that apparently found evidence of “harm” (Grannis et al., 2003) was entirely misreported. The evidence review states that those taking oestrogen had significantly higher depression, suicidality and social anxiety scores than those not on hormones. In fact, Grannis et al. found no statistically-significant differences on these measures.


5. Impacts of Treatment Withdrawal

As far as we are aware, NHS England has no plan to monitor the impact of this withdrawal of gender-affirming healthcare on patient outcomes. This is despite evidence that removal of gender-affirming care is associated with adverse mental health outcomes, including increased suicidality among trans youth.

A decision to withdraw a treatment must consider what alternatives will be provided. Psychotherapy or psychosocial support alone – all that is currently available via the NHS – has not been demonstrated to be an effective treatment for those with a diagnosis of gender dysphoria. Nonetheless, as far as we know, NHS England has no plans to conduct a similar evidence review of
this intervention.


6. Conclusion

In summary, a drastic and potentially devastating policy change that runs counter to international standards of care has been advanced:

  • without any clear rationale,
  • on the basis of a methodologically-flawed process,
  • in the absence of peer review,
  • and without plans for monitoring impact or mitigating harm.

We therefore urge NHS England to:

  1. pause and reverse implementation of any policy changes arising from this flawed review process,
  2. publicly acknowledge and take into consideration the existing University of York systematic review into gender-affirming hormones and the existing EPPI-Centre study,
  3. ensure any clinical commissioning policy on gender affirming hormones for under-18s reflects established international best practice,
  4. and incorporate patient and clinician consensus and testimony into any decision about transgender healthcare.

A full list of signatories can be found here.

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

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

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

TRANSCRIPT

Hi, I’m Ruth Pearce.

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

And I was a trans child.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

FOOTNOTES

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

It appears that much of the widely-lauded NHS Scotland Gender Reassignment Protocol will be adopted in England from 1st June 2013.

This will be a temporary measure, taken as the result of “inconclusive feedback through the consultation exercise on specifications and policies” for the English Protocol. Last year, the draft English Protocol was criticised by many trans people for failing to live up to the progressive standard set by the Scottish Protocol. I wrote about this here.

This information comes from a letter written to stakeholders in the Gender Identity Services Clinical Reference Group.


What will this mean for English patients in the short term?

As the Scottish Transgender Alliance noted in July 2012, the Scottish Protocol “is not perfect but it is an important step forward for trans people in Scotland“. It incorporates a number of clauses that ensure relatively swift access to services (including hormone therapy and surgeries) for those already “in the system” and on the books of a Gender Identity Clinic (GIC).

Key features of the temporary Protocol for England would therefore include:

  • that psychotherapy/counselling, support and information should be made available to people seeking gender reassignment and their families where needed.
  • that two gender specialist assessments and 12-months experience living in accordance with desired gender role are needed for referral for NHS funded genital surgeries
  • only one gender specialist assessment is needed for referral for speech therapy, hormone treatment and FtM chest reconstruction surgery and that these can take place in an individualised patient-centred order either prior to starting the 12-month experience or concurrently to the 12-month experience.

(Bullet points from the Scottish Transgender Alliance. Emphasis mine.)

All of these provisions should (in theory!) entail a more rapid, efficient access to services for patients at many English GICs.


Exceptions

Unfortunately, several particularly progressive aspects of the Scottish Protocol will not be adopted in England. According to the letter sent out to stakeholders, these include:

  • Referral to Gender Identity Clinics (access)
  • Facial hair removal
  • Breast augmentation

“Discussion on these areas” is being “deferred” because “it is recognised these need further discussion and also because England’s health service is structured differently and therefore a slightly different approach will be necessary”

The first point (“referral to Gender Identity Clinics”) is somewhat ambiguous, but appears to mean that provisions made in Scotland for self-referral and referral by GP to GICs will not be implemented in England, at least in the short term. Most English GICs currently only accept referrals from mental health specialist such as psychiatrists, so this looks set to continue.

The letter further states that:

“[…] decisions relating to direct access, facial hair removal and breast augmentation being deferred by all NHS England Area Teams until after the June meeting when further work can be undertaken to reach the interim NHS England Policy and Specification for adoption. Where an individual has already had agreement for any of these procedures then these would go ahead, the deferment relates to decisions not yet made.”

This would appear to imply that no new referrals will be provided for facial hair removal and breast augmentation on the NHS in England, at least for the time being. In most parts of the country this is the norm, but in some areas this will effectively be a step backward.


What about young people?

A final significant aspect of the Scottish Protocol is that it provided for the provision of better services young trans people:

  • that young people aged 16 are entitled to be assessed and treated in the same manner as adults in terms of access to hormones and surgeries.
  • that children and young people under age 16 are entitled to child and adolescent specialist assessment and treatment as per the relevant section of the WPATH Standards of Care.

(Bullet points from the Scottish Transgender Alliance. Emphasis mine.)

It’s not clear whether or not this part of the Protocol will come into play in England, but I suspect that this counts as “access to Gender Identity Clinics”, meaning that nothing will change – in the short term at least.


Analysis

I would suggest that this development is, on the whole, a positive one for the majority of trans patients in England. It will hopefully ensure a number of improvements in access to treatment, particularly for individuals seeking hormone therapy and individuals on the transmasculine spectrum seeking chest surgery (including for individuals seeking chest surgery prior to hormone therapy, or chest surgery without any accompanying hormone therapy). It should encourage GICs to acknowledge trans diversity and provide treatment more adequately tailored to individual circumstance.

Moreover, the implementation of this Protocol means that some of the more regressive elements of the draft English Protocol (such as the requirement for GPs to undertake a “physical examination” ) will hopefully not see the light of day.

Of course, there will continue to be resistance from some of the more conservative GICs. However, the existence of the temporary protocol should empower patients who wish to make the case for better services from these bodies.

It is important to note once again that this is a temporary measure, and that the new English Protocol that is eventually implemented may not necessarily reflect the Scottish Protocol to such a great extent. A meeting will be held in June for members of the Clinical Reference Group to discuss what might happen next. We can only hope that the outcome will be a positive one for trans patients.

However, this move sets an important precedent. A set of relatively progressive new rules are being put in place, meaning that it should be harder for GICs to justify inadequate service provision. This is a new benchmark which health campaigners can use as a starting point for future campaigns.

Finally, the “inconclusive feedback” from “consultation” suggests that pressure from trans health advocates is actually having an effect, particularly as many GICs will no doubt have been pushing for a continuation of the status quo. Credit is due to all those individuals and organisations that responded to the consultation on the draft English protocol a year ago, and members of the Clinical Reference Group who are pushing for positive change.