On 8 February 2021, Brighton and Sussex University Hospitals NHS Trust published a series of groundbreaking resources on perinatal care for trans people, written by their Gender Inclusion Midwife team. As of March 2025, the Trust no longer exists, the midwives in question work elsewhere, and the resources page was sadly taken down – a sadly all-too common experience with NHS guidance for working with marginalised peoples.
Given the importance of these materials, for which I was part of a large team of expert reviewers, I am reproducing them on my website today for Trans Day of Visibility 2025, alongside some related resources.
I hope these will be of interest and use to anyone interested in improving perinatal care for trans people, including midwives, nurses, doctors, policymakers, commissioners, advocacy groups, and of course also families and prospective parents.
Professional guidance and protocolsby the Gender Inclusion Midwives
It’s been a long four years since the Gender Inclusion Midwives resources were published. Here, therefore, are a few additional materials that may be of help to people working in this area.
National Maternity Survey data on trans birth parents Since 2021 the Care Quality Commission has collected data on gender modality as part of its annual National Maternity Survey. The most recent findings indicate a significant rise in the number of men and non-binary people giving birth since 2021, with 1.58% of 2024 respondents indicating a gender that differs from the sex they were assigned at birth. This shows that hundreds of trans people are giving birth in England every year. See: Open data > 2024 Maternity survey National tables > page g9.
Improving Trans and Non-Binary Experiences of Maternity Services (ITEMS) 2022 report published by the LGBT Foundation, looking at the findings of an English study on the experiences of 121 trans people who conceived and gave birth. It found that many trans birth parents do not feel safe sharing their identity in perinatal services, with a large proportion not feeling comfortable to access any support at all from an NHS or private midwife.
Trans Pregnancy Project website I reviewed the Gender Inclusion Midwives resources as part of my work on the Trans Pregnancy Project, which was an international study of trans people’s experiences of pregnancy and childbirth. This year we launched a new website. This includes links to all our peer-reviewed publications, on topics including conception, pregnancy loss, midwifery, gender and embodiment, domestic violence, racialisation, and media representation.
Caring for Everyone: Effective and Inclusive Communication in Perinatal Care One of the key recommendations of the Gender Inclusion Midwives’ guidance on Gender Inclusive Language in Perinatal Service is the adoption of “additive” language. This approach acknowledges male and non-binary birth parents alongside mothers, rather than simply replacing woman-centred language with a gender-neutral approach. This 2025 academic article by Matthew Cull, Jules Holroyd, and Fiona Woollard provides advice on a “pluralist” approach to language, which builds upon the additive model by offering a more contextual approach. It includes clear examples of what best practice can look like.
This morning I logged into instagram and watched, transfixed in amazement and worry, as a young person scaled the walls of the Department for Education.
The aspiring spiderman is part of the activist group Trans Kids Deserve Better. At the time of writing they are staging a multi-day protest at the Department for Education building in London, for the right to a safe and inclusive education.
Watching the video, I fear for Squirrel, the anonymous activist who is genuinely risking their life to stop government employees from taking the group’s banner. It’s very apparent that Squirrel is a skilled climber who knows what they are doing – equally, one wrong move could result in a deadly drop to the concrete pavement. This is not safe.
But of course, the entire reason this protest is happening is because young trans people are not safe.
Trans Kids Deserve Better launched their campaign for youth autonomy, safety, respect, and inclusion in July, from a dramatically high ledge of an NHS England building. In an interviewwith Jess O’Thompson for Trans Writes, the emergency doctor and children’s TV presenter Dr Ronx Ikharia argued that “our young people deserve better than suffering, and shouldn’t be scaling walls”. But they added that for this to happen, trans kids must be “believed, supported, affirmed, and loved”.
And this is the crux of the issue. Under the Conservative and Labour governments, we have seen a policy environment in which teachers, doctors, therapists and parents are actively discouraged or prevented from believing, supporting, affirming, or loving young trans people. Instead, families face prison sentencesfor supporting young people’s continued access to medication, NHS England is expanding the provision of state-funded conversion clinics, and a growing number of schools are refusing to allow even the discussion of trans experiences.
Trans kids are not safe because they have been entirely failed by the adult world. They have been failed by politicians, failed by civil servants, failed by the NHS, failed by the voluntary sector, failed by researchers, and in many cases also failed by their doctors, teachers, and parents or carers. This is why the activists from Trans Kids Deserve Better are literally scaling walls in their fight for an actual future.
Looking at the challenges facing young trans people, it can be easy to lose hope. But the actions of Trans Kids Deserve Better show that there is a better way. Doomerism helps nobody. The successes of successive liberation struggles have come about because people have continually dared to believe that a better world is possible, and fight for it. The young people currently sat outside the Department of Education are not bemoaning what they have lost: they are insistently demanding change.
Image from Trans Kids Deserve Better
What can we do? In their conversation with O’Thompson, activists from Trans Kids Deserve Better explained that while trans adults often want to “protect” trans youth, they would rather we “amplify” them: “we don’t need sympathy, we need support”. This is a call to action, with a focus on solidarity, rather than trying to speak for young people or bemoan their situation.
Many adult trans people and allies have complained about the lack of mainstream media coverage for the actions of Trans Kids Deserve Better. But we should not simply wait for the papers or news programmes to start caring. It’s up to us to talk about what’s happening. Today’s queer and trans communities only exist at scale because we made our own media, told our own stories, and forced the mainstream to catch up.
So I encourage everyone who reads this to share the story of what is happening. Share it on social media, share it with friends and family, share it in conversations at work and in bars and in cafes and in parks and at gigs and festivals. A few days ago I was at a pub in Bath, fresh from Pride, still holding a placard that read “Ban Wes Streeting” (copied shamelessly from someone else in Glasgow a couple of weeks prior). Someone asked what Wes Streeting had done, so I told her. She was appalled, but grateful to have learned what is happening, and better informed to act. Information spreads when we spread information.
If you, like me, would rather not see young people risking life and limb by climbing public buildings, it is time to fight with them, not “for” them. Together we can build a safer world.
I have co-authored an article with Cal Horton for the science magazine Scientific American. We take a concise look at what the Cass Review is, what it found, why the methods used were troubling, and how it is being used to harm young people.
You can read the article here. I hope it will be helpful as a basic explainer for why trans community groups, academic experts, and clinical specialists are so concerned about the Cass Review.
Writing for Scientific American was a really interesting experience. It was of course radically different to publishing in a peer-reviewed journal: we put the piece together in a matter of weeks, and it was not scrutinised by academic experts from our specific field of study. At the same time, there was an extremely rigorous editorial, fact-checking, and copyediting process that also made it very different to publishing in most magazines or newspapers.
I was deeply impressed with the sheer amount of time and care the Sci Am editors put into this piece. On one hand, their contributions ensured the piece is written in accessible language, with an international (and especially US-based) readership in mind. On the other hand, we had extensive discussions to ensure that all points made in the article could be rigorously evidenced, including some very detailed exchanges about the specifics of UK law, and what exactly the Cass Review document does and does not have to say about exponential growth over different periods of time. We had to be able to strongly back up any even slightly contentious point.
It was a challenging experience, but one I felt very held by as an author committed to consciencious research practice. Publishing this piece in Sci Am definitely ensured that it was as good as it could possibly be.
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.
Wednesday 10 April 2024 saw the long-awaited publication of the final report of the Cass Review. This report was commissioned by NHS England, and provides a review of evidence plus recommendations regarding gender identity services for children and young people. It costed £3 millionto produce.
On publication, the Cass Review’s findings and recommendations were welcomed by the majority of UK media outlets, NHS England, the Editor-in-Chief of medical journal the BMJ, conversion therapy proponents such as SEGM, Sex Matters and Transgender Trend, plus spokespeople for the Conservative and Labour parties, who promised to ensure it will be “fully implemented”.
Conversely, the Review has been extensively criticised by trans community organisations, medical practitioners, and scholars working in fields including transgender medicine, epidemiology, neuroscience, psychology, women’s studies, feminist theory, and gender studies. They have highlighted problems with the Cass Review that include substandard and inconsistent use of evidence, non-evidenced claims, unethical recommendations, overt prejudice, pathologisation, and the intentional exclusion of service users and trans healthcare experts from the Review process.
This post provides a round-up of links to written commentary and evidence regarding problems with the Cass Review, plus quotes pulled from each. In light of these, I believe that current attempts to implement many of the Review’s recommendations are both misguided and harmful.
Readers who agree with me may wish to take actions including:
writing letters to MPs and other political representatives, NHS and professional bodies;
raising awareness within voluntary sector organisations and trade unions;
“The Cass Review’s internal contradictions are striking. It acknowledged that some trans young people benefit from puberty suppression, but its recommendations have made this currently inaccessible to all. It found no evidence that psychological treatments improve gender dysphoria, yet recommended expanding their provision. It found that NHS provision of GAMT [gender-affirming medical treatment] [..] was already very restricted, and that young people were distressed by lack of access to treatment, yet it recommended increased barriers to oestrogen and testosterone for any trans adolescents aged under 18 years. It dismissed the evidence of benefit from GAMT as ‘weak’, but emphasised speculative harms based on weaker evidence. The harms of withholding GAMT were not evaluated.”
“The administered ‘therapy’ included psychologically coercive and aversive practices with the goal of gender-typical, heterosexual outcomes. […] Although the 1987 article concluded that J’s case, among others, provided evidence that such therapy can ‘help’ similar children, J’s account indicates that all this treatment ultimately did was cause trauma and suppress her self-acceptance for 22 years. […] The 1987 publication should not be considered reputable evidence in any debate over transgender policies — either by direct or indirect citation. And yet, this article and publications of a similar age and theoretical background continue being referenced as if they were factual and reliable, by actors ranging from the Endocrine Society and the Cass Review to a parent support group[.]”
“Unfortunately, the Review repeatedly misuses data and violates its own evidentiary standards by resting many conclusions on speculation. Many of its statements and the conduct of the York SRs [systematic reviews] reveal profound misunderstandings of the evidence base and the clinical issues at hand. The Review also subverts widely accepted processes for development of clinical recommendations and repeats spurious, debunked claims about transgender identity and gender dysphoria. These errors conflict with well-established norms of clinical research and evidence-based healthcare. Further, these errors raise serious concern about the scientific integrity of critical elements of the report’s process and recommendations.”
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Professor Gordon Guyatt and colleagues [added 15/10/25] Systematic reviews related to gender-affirming care (statement led by the original pioneer of evidence-based medicine – while it does not explicitly name the Cass Review, it is highly relevant given the Cass team’s approach to conducting and interpreting systematic reviews, as noted in this analysis by Gideon Meyerowitz-Katz)
“Following fundamental principles of humane medical practice, clinicians have an obligation to care for those in need, often in the context of shared decision making. It is unconscionable to forbid clinicians from delivering gender-affirming care.”
“One of the overt criteria that the NHS followed in choosing Hilary Cass was her complete lack of experience in working with people with gender incongruence and dysphoria […] The common thread of many objections to the Cass report is the multifaceted downplaying of the importance of the voices of adolescents and their families, clinical practice, the scientific knowledge base, and national and global recommendations, while misleading the public that a complete lack of clinical experience in a given field is a guarantee of reliability. As a multidisciplinary team of experts and patients, we consider such a trend to be harmful and completely contrary to the interests of adolescents in need of help.”
“[I]t is very unusual in the history of medicine that a time-honoured treatment, with a good safety record, even if based on non-randomised trials and experts’ opinion, is simply banned, while waiting for better evidence.”
“Ultimately our responsibility is to offer compassionate, evidence-informed treatment to patients so that they get to decide what is best for them, given what is known and unknown about the risks and benefits of an intervention. To do otherwise would be failing in our scientific mission to ensure that gender affirming care is safe, effective, patient-centered, timely, efficient, and equitable[.]”
“Regardless of what Dr. Cass’ intentions may or may not have been, the Cass Review process itself intentionally and explicitly excluded any oversight from patients and their families and trans healthcare experts, and its content is not supported by a robust methodology. The Cass Review relies on selective and inconsistent use of evidence, and its recommendations often do not follow from the data presented in the systematic reviews. The Cass Review deprives young trans and gender diverse people of the high-quality care they deserve and causes immense distress and harm to both young patients and their families.”
“[…] while waiting for research results, not providing transgender adolescent care that may include puberty blockers and hormones to adolescents who experience gender incongruence is not a neutral act given that it may have immediate as well as lifelong harmful effects for the young transgender person. Also, asking transgender adolescents to participate in research as the only way to receive puberty blockers, as Cass recommends, is unethical.”
“Members of the BMA’s Council recently voted in favour of a motion which asked the Association to ‘publicly critique the Cass Review’, after doctors and academics in several countries, including the UK, voiced concern about weaknesses in the methodologies used in the Review and problems arising from the implementation of some of the recommendations. […] The BMA has been critical of proposals to ban the prescribing of puberty blockers to children and young people with gender dysphoria, calling instead for more research to help form a solid evidence base for children’s care – not just in gender dysphoria but more widely in paediatric treatments.”
“We are aware that this week’s release of the Cass review raises many questions and uncertainties for people accessing or wanting to access gender identity services, as well as for the staff working in those services. We also know that this is likely to be a source of significant distress and worry. On first glance, BAGIS Council are deeply troubled by some of the content of the Cass Review and the potential impact thereof. We will be considering this lengthy document carefully, and in detail, before offering a comprehensive response to its recommendations and before making any relevant observations regarding the process that has underpinned them.”
“The final Cass Review did not include trans or non-binary experts […] in its decision-making, conclusions, or findings. Instead, a number of people involved in the review and the advisory group previously advocated for bans on gender affirming care in the United States, and have promoted non-affirming ‘gender exploratory therapy’, which is considered a conversion practice.”
“The Cass review recommendations are at odds with the current evidence base, expert consensus and the majority of clinical guidelines around the world.”
“[…] multiple relevant international organizations, including the Endocrine Society in the United States, have made statements to the effect that the issues pointed out by the Cass Review were already known, that puberty suppression treatment has been developed over many years, and that determinations on things such as the efficacy and safety of puberty suppression treatment should be made based on scientific findings […] WPATH 8th edition SOC in regards to the effectiveness, limits, and side-effects [of puberty suppression treatment] is written based on a greater number of systematic reviews than the Cass Review.” [p.17, translation by What The Trans, checked by myself with Google translate]
“Welche weiteren Personen außer der Autorin auf welche Art in der Erarbeitung des Reviews beteiligt wurden, ist nicht dokumentiert. […] Medizinische Fachgesellschaften wurden an der Erstellung des Berichts nicht erkennbar beteiligt. Es wurde eine sogenannte „Assurance Group“ berufen, welche jedoch ausdrücklich nicht an der Erarbeitung von Empfehlungen des Cass Reviews beteiligt war. Es liegen Berichte vor, dass außerdem ein „Advisory Board“ eingerichtet wurde. Die Zusammensetzung sowie der konkrete Beitrag dieses „Advisory Boards“ sind nicht dokumentiert[.] Es lässt sich insofern keine Einschätzung über die Expertise der Mitglieder abgeben.”
“It is not documented which other people, apart from the author, were involved in the preparation of the review and in what way. […] Medical societies were not identifiably involved in the preparation of the report. A so-called “Assurance Group” was appointed, but it was expressly not involved in the development of recommendations for the Cass Review. There are reports that an “Advisory Board” was also set up. The composition and specific contribution of this “Advisory Board” are not documented[.] It is therefore not possible to make any assessment of the expertise of the members.“
“TACTT is deeply concerned by the final report of the Cass Review, whose core underlying premise is effectively an eliminationist agenda, dressed up in the language of ‘reasonableness’ […] We urge clinicians to treat the Cass findings with extreme caution and not to assume that they represent best practice or that they have been arrived at after a full and impartial review of clinical data.”
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Endocrine Society (USA and international) Statement from Endocrine Society[added 15/05/24] Note: statement prepared in response to an interview with Hilary Cass for the ‘On Point’ podcast.
“NHS England’s recent report, the Cass Review, does not contain any new research that would contradict the recommendations made in our Clinical Practice Guideline on gender-affirming care. […] Although the scientific landscape has not changed significantly, misinformation about gender-affirming care is being politicized.”
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American Academy of Pediatrics (USA) Statement from American Academy of Pediatrics[added 15/05/24] Note: statement prepared in response to an interview with Hilary Cass for the ‘On Point’ podcast.
“The AAP’s gender-affirming care policy, like all our standing guidance, is grounded in evidence and science. […] What we’re seeing more and more is that the politically infused public discourse is getting this wrong and it’s impacting the way that doctors care for their patients. […] Politicians have inserted themselves into the exam room, and this is dangerous for both physicians and for families.”
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Dr Max Davie and Dr Lorna Hobbs [added 08/08/24] (Consultant paediatrician and clinical psychologists – former education leads for London’s new child and adolescent gender services) Cass: the good, the bad, the critical
“The fact that any new prescriptions of puberty-pausing medication for someone under 18 is now a criminal offence in the UK may be shocking, but to those of us who were observing the Cass review it is not surprising. Dr Cass was known by colleagues to oppose medical transition when she was appointed to the review, after all.”
“[…] one experienced psychiatrist at a gender identity clinic in England – who did not wish to be identified – told the Sunday National that failure [to include those with lived or professional experience] had concerned many within the field. They said: “The terms of reference stated that the Cass Review ‘deliberately does not contain subject matter, experts or people with lived experience of gender services’ and Dr Cass herself was explicitly selected as a senior clinician ‘with no prior involvement … in this area’. ‘Essentially, ignorance of gender dysphoria medicine was framed as a virtue. I can think of no comparable medical review of a process where those with experience or expertise of that process were summarily dismissed’.”
“’There have been multiple expert academic treatises written on what was wrong with the Cass Review … they intentionally sidelined people who worked in the field,’ [Brisbane GP Dr Fiona Bisshop] told The Medical Republic. ‘Practitioners who worked with trans patients and trans people themselves were excluded from that whole review, and that didn’t happen [in Queensland]. They talked to the right people who were using the service and they also included some people in the review panel who were experts.’”
Responses and publications from expert researchers and educators
“Using the ROBIS tool, we identified a high risk of bias in each of the systematic reviews driven by unexplained protocol deviations, ambiguous eligibility criteria, inadequate study identification, and the failure to integrate consideration of these limitations into the conclusions derived from the evidence syntheses. We also identified methodological flaws and unsubstantiated claims in the primary research that suggest a double standard in the quality of evidence produced for the Cass report compared to quality appraisal in the systematic reviews.”
“The Cass Review relies on six systematic reviews of different aspects of healthcare for young people accessing gender identity services. Systematic reviews are a way of compiling information from multiple studies that have looked at the same topic and come to an overall understanding of the results. There are very specific guidelines for how systematic reviews should be done but the Cass Review’s systematic reviews deviated from best practice in systematic review methodology in several ways […]”
“While the Cass Review has been presented by the U.K. media, politicians and some prominent doctors as a triumph of objective inquiry, its most controversial recommendations are based on prejudice rather than evidence. Instead of helping young people, the review has caused enormous harm to children and their families, to democratic discourse and to wider principles of scientific endeavour.”
“Inductive and deductive reflexive thematic analysis was applied to a collection of Cass Review publications related to trans children’s healthcare published between January 2020 and May 2023 […] Four concerns are presented and explored: (1) prejudice; (2) cisnormative bias; (3) pathologization; and (4) inconsistent standards of evidence. Each of these concerns impacts the Cass Review’s approach to trans children’s healthcare, with negative repercussions for trans children’s healthcare rights and well-being.”
“Each of the recommendations summarised below is built on a foundation of prejudice, ignorance, cisnormativity and pathologisation of trans lives, running in direct opposition to the evidence base, and running in direct contravention of an NHS duty of care to children’s rights, children’s welfare, healthcare equality and healthcare ethics.”
“The Cass Review has shown zero evidence of harms of social transition or puberty blockers. The only harm is this hypothesis that they change the trajectory and outcome, locking children into a trans lifetime. This hypothesis is based on the worst quality evidence I’ve ever seen. This is why trans healthcare researchers are feeling stress and dismay at UK media and politicians cheering on Cass’ evidence-based policy.”
“In this commentary, this scientific evidence is reviewed, particularly focusing on the biological and psychosocial claims reported in the [Cass] Review. The scientific substantiation of assertions in the sections on understanding the patient cohort and clinical approaches is examined critically, resulting in the finding that the Review shows a number of issues that together point to a substandard level of scientific rigor in the Review. As such, it called in question whether the Review provides sufficient evidence to substantiate its recommendations to deviate from the international standard of care for trans children.”
“Zoals vele artikelen, waaronder mijn eigen recentelijke publicatie, hebben aangetoond, is het onderzoek van Cass echter zélf wetenschappelijk zwaar onder de maat. Het geeft bijvoorbeeld geen statistische onderbouwing van kwantitatieve claims. Ook gebruikt Cass eenzijdige bronnen voor haar aanbevelingen. Het rapport versimpelt verder veel lastige biologie, zoals het idee dat het brein pas volwassen is als je 25 bent.”
“However as many articles, including my own recent publication, have shown, Cass’s research itself is scientifically seriously substandard. For example, it provides no statistical substantiation of quantitative claims. Cass also uses one-sided sources for its recommendations. The report also simplifies a lot of difficult biology, such as the idea that the brain is not fully mature until you are 25.“
“It needs to be emphasized here that even The Cass Review found no empirical evidence of harm being caused to young trans people by puberty-blockers. This study, however, demonstrates that banning them causes very significant harm indeed. […] By far the most consistent prevailing theme to come out of the data was that of the overwhelming levels of distress these young people are experiencing[.]”
“Despite the concern-laden language about “helping” and “supporting” trans children, it is my opinion that what Cass is attempting to establish is an all-enveloping ambient conversion therapy approach to trans children, removing their autonomy, freedom of expression, mental health, helpful support and healthcare. […] If imposed it will, in my view, result in the deaths and deterioration in mental health of many trans children.”
“The Cass Review […] demonstrates that transphobic pop-cultural discourses have real material effects. Transphobic discourses became increasingly publicly popular, which led to increased criticism of current care models for trans youth. Heightened public scrutiny led to the Review’s commissioning and the subsequent banning of puberty blockers. There is a direct line between public discourse and restrictions on trans rights.”
“The Review does not make it clear that such a significant proportion of the experts it relies on do not believe in [the existence of] transgender children or that the root cause of distress in this population is gender. It may be unclear to policymakers and the public that people holding such views are shaping practice norms.”
“[…] above all else, the Cass teams disregarded evidence supporting trans care. They did so by starting their research from the position that trans care is a problem which must be solved in the first place. […] They started from the logic of a pandemic, expressed in the fear of a “social contagion” capable of upending cisgender supremacy, and in so doing, they created the conditions to make evidence that would assert a position of cis-supremacy.”
“I will argue that some of the recommendations contained in the Cass Review are not congruent with ethical norms concerning clinical research involving minors. There are sound reasons to perform clinical research in this area, and the investment in research is to be welcomed. However, a clinical trial is unlikely to enhance the evidence base.”
“Our concern here is that the Review transgresses medical law, policy, and practice, which puts it at odds with all mainstream U.S. expert guidelines. The report deviates from pharmaceutical regulatory standards in the United Kingdom. And if it had been published in the United States, where it has been invoked frequently, it would have violated federal law because the authors failed to adhere to legal requirements protecting the integrity of the scientific process. […] More generally, the Review’s circumscribed approach to drug approvals is out of step with pharmaceutical law and policy in both the United Kingdom and the United States. […] The [final] report’s application of a heightened evidentiary standard probably stems in part from its deviation from standard medical scientific process. Specifically, it lacked peer review, transparency of authorship, and equitable selection of nonauthor contributors.”
“Trust in research is not only fragile, but it is built on, over time. When this gets eroded or broken (as in the Cass Review), it creates a highly volatile environment for the medical and scientific community to try and shift.”
“In the USA, the 2025 HHS Gender Dysphoria Report […] it dismisses decades of clinical practice and undermines the legitimacy of care models that affirm youth gender identities. Like the Cass Review, it frames gender-affirming care as inherently suspect, requiring extraordinary proof to be considered safe. The resulting policies render timely care inaccessible, especially in politically hostile states. Neither report applies comparable scrutiny to irreversible paediatric interventions in other contexts, such as intersex care, nor do they address the harms of care denial or of imposition of questionable care.”
“Cass’ conclusions generally focus on limiting or minimizing medical GAC for youth and she also minimizes the robust data and the potential negative impact of increasing barriers for an already disenfranchised group.”
“The [Cass Report] is not a clinical guideline or a working manual. Unlike the systematic reviews from which it draws its conclusions, the report is not a scientific publication and was not submitted to a peer-reviewed journal. Furthermore, it does not produce new evidence or find any evidence of harm caused by social transition and the use of medical treatments such as puberty blockers and cross-sex hormones. […] [Critical reports] have compellingly exposed some of the report’s methodological flaws and the undue interpretation of the report by those who have used the document to advance their own anti-rights agendas.”
“Whilst the report cites adjacent NHS services using 0-25 models to justify a ‘continuity of care’ (224), designating trans persons as ‘vulnerable’ and confining them to child-oriented services indicates that more is at stake. These rhetorics contribute to the shoring up of state surveillance and intervention into the lives of legal adults who want to make choices the state disagrees with.”
“One of the main arguments that the Cass review has made is that there has been a dramatic and hard-to-explain increase in the number of children who identify as transgender and attend UK clinics with gender dysphoria seeking help. In a number of places, the review describes this increase as “exponential”, and notes that it appears to have been accelerating in recent years. […] The authors say that this increase is far too big to be caused by social acceptance of trans people, and therefore there must be some form of pernicious influence such as social media, mental health problems, or some other issue causing kids to become trans at increasing rates. […] But if you look at the actual data in the reports that the review is discussing, not only is the increase not exponential, it’s not actually that surprising.”
“I think it’s important to stick to the facts when critiquing a review such as the Cass report. […] I think the review made some serious mistakes in both science and interpretation, but they didn’t simply discard most of the evidence, or sneakily change their methodology to get rid of important research. The real story of the Cass review is much more complex than a single weakness that entirely discredits the work.”
“Some of the main arguments AGAINST using hormones and medications for transgender children are contradicted by the Cass review. Barely anyone has noticed, because the review mentions this fact once in a single paragraph, and most of the data is relegated to Appendix 8. […] This should be a key point. A chapter of the review. “Common arguments against giving transgender children medications are wrong”. Instead, it’s a footnote. That raises all sorts of red flags. Why were these key findings shunted to an appendix and largely ignored?”
“The [Cass Review] authors cite conversion clinics as evidence that transgender children rarely experience dysphoria as adults, use incredibly low-quality research to support the idea that detransition is more common than we might imagine, and almost entirely avoid the data which shows that most transgender people – including children – persist in their identities and do not regret their transition.”
“One of the strangest parts of the Cass review is the speculation on the potential negatives that medications may have […] For a review that spends a great deal of time bemoaning the state of the evidence supporting transgender care, this is an astonishing thing to do. The cited reference [on brain maturation being disrupted by puberty blockers] is a speculative theory about the importance of pubertal hormones on mice, with no follow-up data in humans.”
“There seems to be a very strong pattern in the Cass review which we are seeing repeated in almost every part of the publication. First, we have a review of the evidence for gender-affirming care in kids. Mostly, the evidence isn’t great. This is an unfortunate fact, and one that I’ve discussed at length. Then, the review will cite various unsubstantiated theories that vary from possible to unlikely to complete pseudoscience. These theories are given equal – or in some cases, greater – weight than the existing evidence in actual trans children.”
“For a document that spends literally thousands of words lamenting the quality of evidence for trans healthcare, it is startling to see that the only therapies that Cass recommends are the ones with by far the worst evidence around.”
“What we can say with some certainty is that the most impactful review of gender services for children was seriously, perhaps irredeemably, flawed. The document made numerous basic errors, cited conversion therapy in a positive way, and somehow concluded that the only intervention with no evidence whatsoever behind it was the best option for transgender children. […] The fact that so many have taken such an error-filled document at face value, using it to drive policy for vulnerable children, is very unfortunate.”
“[The Cass Review] is just a review. In my previous essay, I cited numerous scientific reviews carried out by experts in the field which all came to a different conclusion than the Cass review: that gender-affirming care is beneficial and gender-disaffirming approaches harmful for trans and gender-diverse youth. If those reviews aren’t “authoritative” enough for you, then how about the American Academy of Pediatrics review, or the Endocrine Society review, or the WPATH Standards of Care, or any of the other health professional organizations who have come to similar conclusions.”
“We suggest that the Cass Review contains unsound methodology, unacceptable bias, and unsupported conclusions. As academics and experts in the field, we regard The Cass Review as potentially harmful to trans children.”
“Some of [the] recommendations follow entirely spurious narratives and draw unfounded conclusions. The whole report is positioned in a way which considers continuation of current medication access as harmful, but removal of the current medication access as a neutral or beneficial act, despite no evidence to support this. We are particularly concerned about the content discussing neurodiversity; social transition; and access to medications for children and young people. The report positions the fact that clinicians are unable to predict the future of children and young people’s gender expression as a critical failing of current practice. No service can or should aim to predict the future of children or young people’s lives and the idea that a clinician will know a young person better than they know themselves is in direct contradiction to the United Nations Convention on the Rights of the Child. The aim for clinicians should be to provide a safe, accessible and supportive service which provides individualised care to all children and young people it encounters.”
“The signatories urged [UK education secretary] Phillipson to undertake three actions: – Restate commitment to, and pursue with haste, a legislative ban [on] all conversion practices. – Welcome the fair criticism of the Cass Review, reflecting the nuance of a complex field and recognising the substantial, widespread international critique. – Meet with us, with a shared commitment to keep inclusion at the heart of our practice, so that we can help build an education system and society where everyone can find a place to belong.”
“I am persuaded that the Cass Review, whilst by no means irrelevant, is deserving of little weight in determining where Ash’s best interests lie. (186) […] The wholly untested Cass Review does not help much, or even at all, since it could only (in this case) recommend that there is nothing that can be done to help Ash. Indeed I must confess the “do nothing” approach […] (albeit practically cloaked as “psychotherapy” – which Ash will not likely accept, even if it could be funded, which on the evidence it could not), troubles me because it seems to work on the assumption that doing nothing is better, which seems to be just kicking the can down the road until Ash is 18, in the hope that, given time, he will change his mind. (248)”
Important note: the conclusion to the judgement adds: “observers may also read this judgment as some kind of refutation of the Cass Review and the views of health professionals who adhere to similar views as expressed in that review, but again it is no such thing. Whilst the Cass Review appears to have some deficiencies, blind spots and limitations, ultimately that is a matter for the UK Government, not an Australian court, to determine” (276). I am sharing the judgement here as I feel it highlights important limitations in the Review even if it does not amount to a formal refutation.
Responses from trans community organisations
Coalition of 100+ LGBTQ+ community organisations and experts Letter to Wes Streeting[added 11/11/24]
“Trustworthy government reviews of the evidence base for a particularly controversial policy, especially in the medical field, do not look like the Cass Review. They have a clear mandate and problem to solve which are raised by those directly affected, not by newspaper columnists or ideologues. They do not exclude members of the patient cohort and those with long-term experience in the field from being part of their team or consider professional or lived experience “bias”. They ensure there is transparency and meritocracy in the appointment of key personnel. They consult openly and in an ongoing fashion with patients and organisations representing them. They do not assume that the treatments in question and anyone involved with them are part of an ideological conspiracy. They are clear and consistent about the evidentiary standards being used to judge any given concerns. They are careful not to give credence to unevidenced theories. They accurately represent the views of those they have engaged with. When problems arise or mistakes are made, they engage with the impacted communities. When strong critiques are made by other experts internationally, these are discussed and engaged with rather than ducked and declared unacceptable to mention.”
Disclosure: I contributed to and signed this letter.
“Decisions are being taken that affect our lives without any trans people in the room, let alone trans young people. Too often trans kids are portrayed as a monolith of confused, depressed teenagers. We are denied choice and robbed of our autonomy. But we should be trusted to make the same decisions about our healthcare that all people are.”
“[…] we believe there to be systemic biases in the ways that the review prioritises speculative and hearsay evidence to advance its own recommendations while using highly stringent evidence standards to exclude empirical and observational data on actual patients. This adds to the concerns we have previously had about Cass excluding trans people from the research oversight board – that Cass was set up from the start to impose a particular perspective without input from the patient cohort affected by the outcome.”
“In the absence of effective treatments for dysphoria outside of transition, ‘alternatives’ rely primarily on impossibilising transition […] any therapeutic paradigm for trans and gender-variant young people must explicitly centre the reality and accessibility of transition and affirm all potential genders/embodiments, and should provide information on what pseudo-therapeutic manifestations of anti-trans rhetoric look like, both in clinical and community settings. Models that do not include this risk endorsing the influence of transphobic hostility on identity formation, for instance, or affirming rhetoric that assigned sex is ‘reality’ when this coheres with a given young person’s identity.”
“Whether Hilary Cass wants conversion therapy to be institutionalised on the NHS again is immaterial: her recommendations have made space for it. Therapy is a caring profession, and despite the crueller parts of its history, good work happens under its banner – but so does violence. The NHS must set out a clear and actionable plan to keep conversion therapy out of its services, and investigate instances where it may have been allowed to take place. Anything else is complicity.”
“In June of 2023 it was disclosed to us by members of the Cass Review team that anti-trans author and commentator Dr Az Hakeem was part of “NHS England’s policy working group which commissioned the NICE evidence reviews undertaken in 2020”. Dr Az Hakeem has long been a partisan opponent of gender affirming medical treatments. While Hakeem disavows conversion therapy or trying to dissuade trans people from medical interventions, on his personal website he directs readers looking for specialist support for gender dysphoria to conversion therapy activist groups, such as Bayswater Support Group, and the anti-trans pseudoscientific lobby group SEGM. Hakeem is also a member of CAN-SG who have from their earliest webinars (link) promoted the idea that trans people should be dissuaded from transition and instead either change their minds, or undergo therapy to live with the discomfort of gender dysphoria without accepting their trans identity — in other words, that trans people should undergo conversion therapy.”
“The report […] strays far beyond its scope and competence in recommending a review of adult services and in suggesting that young people ought to stay under the care of children and young people’s services until the age of 25. The latter is based on highly questionable understandings of brain development which have been repeatedly debunked as an oversimplification of the constant changes in human neurology over the course of our lives. […] Underpinning this report is the idea that being trans is an undesirable outcome rather than a natural facet of human diversity. This is clear not only from the recommendations but also from the exclusion of trans researchers from the design of the review process and the links individual members of the research team have to anti-trans groups, which the Cass team were warned about.”
“The Report dismisses almost all evidence around existing protocols for treating trans young people, including lived experience, on the spurious grounds it does not meet unobtainable levels of proof. The team do not apply the same rigorous evidential tests to their own proposals. Indeed, if such evidential requirements were imposed consistently and equally across the NHS, it would mean that many routine treatments, including treatments for menopause, palliative care and mental health, would also have to cease.”
“Of note, many other paediatric medications that are routinely used in paediatric care, do not and cannot have the level of evidence that Cass and NHS England demand: medicines for ADHD, for example, anti-psychotic medications, and many others have comparable if not lower levels of evidence.”
“I was invited to consult with the Cass review. After three discussions it was obvious that the review had been written before we started. She totally discounted evidence from trans people from the basis of knowledge or lived experience.”
“Young people we have spoken to are concerned about what they have read, including the desire to understand “why” young people are trans, and to place what feel like “limits” on gender expression, further pathologising and medicalising their identities. We share these concerns. We are deeply frustrated with the lack of clarity throughout the report, which has enabled wilful misinterpretation and the spread of harmful misinformation. Clear and accessible language is vital, especially when services are operating in a context where there is significant hostility to and misconceptions about trans people, particularly in the media. “
“In the world the Cass Review imagines a trans child will be seen quickly but not given the care they need. They will still wait for years if they want to access gender affirming healthcare. While they wait they will be expected to engage with therapy that risks becoming conversion practice. While they wait, they will go through a puberty they may find profoundly distressing. They will be treated for every other condition they have. They will be treated for conditions they develop as a consequence of denial of trans healthcare and living in a transphobic world. But they won’t get the care they need to feel comfortable in their own skin. This is a model of care that works for cis people who are upset by the idea of a trans child existing.”
“The NHS has always been a violent, white supremacist, saneist, transphobic system; the Cass Report was never going to change that system, indeed it was designed to expand it. The NHS does not provide trans healthcare: it disciplines and punishes trans people, so we will transition in any way we can – with community-led care, private care, and overseas care. We will smuggle, borrow, share, and steal the medicine we need. We will take direct action to protect each other. We survive. We rebel. Fuck the NHS.”
“Politicians will continue to create moral panics to distract and divide us from their own failings. The Cass Review, instead of focusing on a lack of funding, long waiting lists and overstretched staff is ultimately calling to restrict trans healthcare. Enough is enough. Trans youth don’t need to be studied, managed or saved. They need the same opportunities and quality of care that their cis friends and family receive.”
Responses from trade unionists and human rights groups
“[T]rade unions’ rejection of what has been framed by the media and political establishment as a ‘moderate’ and ‘reasonable’ line on trans rights should be seen as a cause for hope. […] Regardless of what comes next, though, we must be guided in everything we do by what trans communities and trans-led organisations are asking for. As members of organisations founded on worker self-representation, “nothing about us, without us” must be at the front of our minds and hearts.”
“This review is being weaponised by people who revel in spreading disinformation and myths about healthcare for trans young people. It’s concerning that sections of the media and many politicians continue to spread moral panic with no regard for the possible consequences for trans people and their families. The negative rhetoric by the Government about the dangers of so-called gender ideology, healthcare for young trans people, as well as the push against LGBT-inclusive sex and relationship education is harmful and extremely damaging.”
“As much as Cass’s report insists that all lives — trans lives, cis lives, nonbinary lives — have equal value, taken in full it seems to have a clear, paramount goal: making living life in the sex you are assigned at birth as attractive and likely as possible. Whether Cass wants to acknowledge it or not, that is a value judgment: It is better to learn to live with your assigned sex than try to change it. If this is what Cass personally believes is right, fair enough. It can charitably be called a cultural, political or religious belief. But it is not a medical or scientific judgment.”
“Though there is much more evidence now to support gender-affirming care than in 2008, there is also a much stronger anti-trans movement seeking to discredit and ban such care. British media coverage has given that movement a big boost in recent years, turning the spotlight away from the realities that trans kids and their families are facing, and pumping out stories nitpicking at the strength of the expanding evidence base for gender-affirming care. Its coverage of the Cass Review followed suit.”
“International medical organizations and transgender activists are roundly condemning a new U.K. report on gender-affirming care for minors, saying the report ignores years of research to propagate “harmful” misinformation.”
“The Report included many recommendations for treatment of youth presenting at gender clinics in England. Some of these were fairly technical, describing proposed relationships between NHS entities such as regional centers, centralized authorities, and local/tertiary providers. Other recommendations were broader […] The recommendations synthesize a view of medical transition as a bad outcome to be avoided, and a belief that gender dysphoria can be successfully treated non-medically, despite no non-medical interventions being evaluated in any of the series of systematic reviews[.]”
“The French Society of Pediatric Endocrinology and Diabetology (SFEDP) recently commissioned its own version of the Cass Review, and this study reached almost the exact opposite conclusions of Cass […] Upon reading both the Cass Review and the SFEDP Review, what immediately jumps out is the very different tone of each—Cass takes a tone that feels skeptical to the point of excess, offering mysteriously curt phrasing, statements rife with implications of harm or conspiracy by mainstream providers, and an overall sense of invalidation. By contrast, the SFEDP Review reads like a scientific paper—its language is straightforward and sterile, and there is none of the innuendo of Cass.”
“This week, when the Cass Review was released, news outlets rushed to cover the story, highlighting the report’s conclusions without taking time to consider whether the report could be flawed. In doing so, it amplified and solidified to the wider public the report’s key conclusions without balancing it against the evidence it excluded to reach them. […] Crucially, despite a four-year process, it still failed to find any smoking gun of widespread regret among trans folks who transition. It instead had to rely on a methodology that allowed it to exclude any data about how gender-affirming care helps trans people.”
“We contend that the Cass Review is not fit for purpose. We suggest that it was not merely knocked off course by a flawed methodology. We believe the Cass Report is a deliberate part of a political project aiming to reduce the availability of trans healthcare, possibly eventually in its entirety. It is imperative that we understand this and act on it.”
“The trans and questioning children who are at the centre of this conversation are in community with one another, and they understand exactly what is happening to them. While we are focussed on the bigger picture, I was taken by their confidence and eloquence when speaking of their experiences. [A speaker shared] a story about speaking to a trans kid they knew through their work, who, speaking of their many friends who had died of suicide: “Yeah, you know how it is.” And we do. We are used to just how extreme what is currently happening to us in the UK is, and the real effects it has on us. We have been sounding the alarm for years, but we are now feeling the UK’s uniquely slow and bureaucratic oppression start to bite[.]”
“Children’s wellbeing is indeed at stake here, but that includes the wellbeing of children who are actually trans. Far from taking the matter out of politics, the review – and Rishi Sunak’s subsequent praise of it – has put it centre-stage. Some readers will remember the climate of homophobia that suffused the run-up to the 1997 general election, when the Conservative Party, desperate as it is now, brought out the “They’re coming for your children” rhetoric in a last-ditch effort to panic people into voting for it. This review – whose final report has been awaited for some time – feels like an attempt at the same thing.”
“It is important to note that the Cass Review contains very little new data and evidence. Any statements it makes are based on the same level of evidence that every major medical organization in the United States, along with some of the largest mental health societies in the world and professional associations of transgender health, have determined to support transgender care. If its claims differ from those institutions, it’s because reviewers made choices to view the evidence around transgender care negatively.”
“The Cass Review seems to have emulated the Florida Review, which employed a similar method to justify bans on trans care in the state—a process criticized as politically motivated by the Human Rights Campaign. Notably, Hilary Cass met with Patrick Hunter, a member of the anti-trans Catholic Medical Association who played a significant role in the development of the Florida Review and Standards of Care under Republican Governor Ron DeSantis. Patrick Hunter was chosen specifically by the governor, who has exhibited fierce opposition towards LGBTQ+ and especially transgender people, and then immediately got to work on targeting transgender care. The Florida review was purportedly designed and manipulated with the intention of having “care effectively banned” from the outset, as revealed by court documents. The Florida Review was slammed by Yale Researchers as “not a serious scientific analysis, but rather, a document crafted to serve a political agenda,” and much of their full critique is applicable to the Cass Review as well.”
“[A] focus on “distress” was used to obfuscate the core purposes of treatments in transgender care. By keeping the reader’s attention on a subset of a treatment’s (often hypothesized) effects, Cass elides ancillary outcomes with the reasons why those treatments are used […] It is urgent to understand that implementing Cass will entrench deeply transphobic ideas and practices within the NHS. The result will be a systematic and dangerous failure to serve the needs of a patient group that is marginalized, maligned, and misunderstood at every turn.”
“The 32 recommendations, informed by the highly conservative evidence base, look to impose further restrictions and control on trans lives — and not just the lives of trans youth with the scope of these recommendations including 25 year olds. Given that we know The Cass Review has been majorly influenced by anti-trans activists with ties to conversion therapy efforts, it’s probably worth looking at some of the recommendations and how they relate back to what transphobes are doing to organise against trans liberation.”
“The overall recommendation is to force patients to wait through psychological busywork and relevant-sounding delays, implementing a largely-arbitrary set of hoops to jump through with the hopes the patient just gives up. Focus on the patient’s anxiety, focus on their autism, focus on any other issue except their gender and their desire for a sex change[.]”
“Earlier this month, WIRED noted that generative AI has a track record of representing queer and trans people as a collage of stereotypes. It is not clear why the Cass team used AI-generated images in this report, which, again, has been used as evidence by the NHS to stop providing gender-affirming care to trans kids.”
“Questions have been raised about the neutrality & evidence basis for the controversial #CassReview. The report’s author Hilary Cass has been asked to provide answers why she is meeting with Women’s Declaration in the House of Lords this week.”
“§6.18 presents us with the idea that toy choice is influenced by hormones. To accept this report is to accept that estrogen, for example, has a biological effect that causes a preference for play with toy cooking pans over toy trucks. In §6.23 we are directed to the work of Melissa Hines in support of this hypothesis. Hines was one of the two authors of the “vervet monkey” study that claimed to show such toy preferences in monkeys. A study that implies something about estrogen makes monkeys want to play with cooking pans.”
“Here is Cass citing “Thoughts On Things And Stuff”. This is a YouTuber whose channel includes a host of anti-trans video material, including material from notorious anti-trans figures, including ‘”‘Gays Against Groomers’.”
“It has been drawn to my attention that [a booklet produced based on research cited by the Cass Review] was funded by SEGM’s William Malone & anti Trans lobby group Transgender Trend.”
“In 2021, Trilby “Tilly” Langton, the sole gender affirming care “expert” involved in the Cass systematic reviews, went to lobby Kemi Badenoch about the conversion therapy ban. With a featured speaker at the 2024 CAN-SG conversion therapy conference.”
“The review found 5 studies of moderate certainty relevant to psychological health. All 5 supported the conclusion that treatment of trans teens with CSH [cross-sex hormones] improved psychological health. There were no findings of worsening psychological health. What conclusions would you draw from this? Our intrepid authors draw no conclusions from this whatsoever, instead declaring the evidence for every outcome for which there was no high certainty study “inconclusive.” Similar is true for other outcomes and for puberty blockers. This is the sense in which the Cass Review absolutely did ignore almost all evidence on the efficacy & safety of PBs [puberty blockers] and CSH. The majority of moderate certainty studies were included in the results section but then arbitrarily ignored in the conclusion entirely.”
“The Cass Review Report does not conclude that puberty suppressing hormones are an unsafe treatment. The report supports a research study being implemented to allow pre-pubertal children to have a pathway to accessing this treatment in a timely way and with suitable follow up and data collection, to provide the highest quality of evidence for the ongoing use of puberty suppressing hormones as a treatment for gender dysphoria. In the data the Cass Review examined, the most common age that trans young people were being initially prescribed puberty suppressing hormones was 15. Dr. Cass’s view is that this is too late to have the intended benefits of supressing [sic] the effects of puberty and was caused by the previous NHS policy of requiring a trans young person to be on puberty suppressing hormones for a year before accessing gender affirming hormones. The Cass Review Report recommends that a different approach is needed, with puberty suppressing hormones and gender affirming hormones being available to young people at different ages and developmental stages alongside a wider range of gender affirming healthcare based on individual need.”
Some final thoughts: recommendations such as this from the Q&A are not clearly reflected in the content of the reportor thelater Q&A published on the Cass Review website. In a blog post accompanying that Q&A, Dr Cass complains about “some of the assertions being made on social media, and occasionally on mainstream broadcast media, which misrepresent the report and its findings, whether wilfully or otherwise“.
In my expert opinion, the critiques linked to in this blog post have yet to be properly addressed by the Cass Review team, let alone any of the politicians or healthcare service directors promising the implementation of the Review’s findings.
Regardless of whatever Dr Cass’ intention may or may not have been, the Review process itself intentionally and explicitly excluded any oversight from service users and trans healthcare experts, and involved collaboration with proponents of conversion practices. The final report relies on poor and inconsistent use of evidence, and makes recommendations that put young trans people in danger.
On Saturday 23 March the Clinical Advisory Network on Sex and Gender (CAN-SG) are hosting at conference at 30 Euston Square, the headquarters of the Royal College of General Practitioners. CAN-SG are described by Trans Safety Network as “an organisation composed mainly of activists involved in the pseudoscience network SEGM, and the anti-trans conversion therapy campaigning body Genspect“.
A noise demonstration will be held outside the conference venue from 10am on 23 March, hosted by Transgender Action Block, Lesbians and Gays Support The Migrants, and The Dyke Project.
According to the Memorandum of Understanding on Conversion Therapy, an agreement signed by 40 leading professional bodies and healthcare providers, conversion therapy “is an umbrella term for a therapeutic approach, or any model or individual viewpoint that demonstrates an assumption that any sexual orientation or gender identity is inherently preferable to any other, and which attempts to bring about a change of sexual orientation or gender identity, or seeks to suppress an individual’s expression of sexual orientation or gender identity on that basis”. Conversion therapy has been described as a form of torture in academic work and by UN experts.
The CAN-SG event speaker lineup is a who’s who of conversion therapy proponents and anti-trans activists, including:
Stelley O’Malley, founder and director of Genspect, who has described seeking to suppress the gender identity of teenagers in her therapeutic work, adding: “I don’t think you should have empathy or sympathy” for young trans girls.
Michael Biggs, an anti-trans campaigner linked to a prolific troll account on Twitter.
Richard Byng, a member of anti-trans pseudoscience network SEGM.
Rachel Cashman, a campaigner against trans inclusion in schools, and supporter of Women’s Declaration International (WDI). Under their former name of Women’s Human Rights Campaign, WDI have openly called for the “elimination […] of the practice of transgenderism”.
Az Hakeem, a member of Genspect and an active opponent of a proposed legal ban on conversion therapy. Hakeem was reported for conversion therapy to the GMC by a former patient.
Anne Hutchinson, who has promoted materials by Genspect in training for South London and Maudsley NHS Mental Health Trust.
Riittakerttu Kaltiala, a Finnish clinician and opponent of affirmative care who contributed evidence for Florida’s ban on medical transition for young trans people. I have not found any evidence that Kaltiala opposed Finland’s policy of forced sterilisation as a condition of legal recognition for trans people, which was repealed only last year, but am willing to be corrected on this. According to a recent academic biography, Kaltiala sits on the advisor board of the Cass Review.
The Royal College of General Practitioners (RCGP) are signatories of the Memorandum of Understanding on Conversion Therapy. Signatories agree that conversion therapy is “unethical and potentially harmful”, and commit to ending this practice in the UK.
Following complaints from LGBTIQ+ groups and their own members, the Royal College of General Practitioners (RCGP) released a statement saying that the conversion therapy conference would go ahead. In the statement, they argue that their headquarters building, 30 Euston Square, is “an event space run by an independent events company”. However, the statement opens by saying that the RCGP has “reached the decision that the Clinical Advisory Network on Sex and Gender (CAN-SG) conference can go ahead”, and later adds that “the College would be at risk of being faced with a claim for breaching the Equality Act if we acted otherwise”. This implies that the RCGP do, in fact, have control over their own building, and have taken the active decision not to oppose the conference.
Legal threats are increasingly common from anti-trans campaigners, who argue that cancelling contracts or events constitutes an attack on their “gender critical” views as “protected beliefs”. The CAN-SG conference has been widely reported as a gender critical event, and indeed several of the speakers appear to describe themselves as “gender critical”. However, the issue with the event is not the beliefs of the speakers or organisers in and of themselves. It is that they are actively promoting disinformation and harmful practices.
The RCGP’s position is therefore one of gross cowardice, and demonstrates that they are not actually committed to preventing harm against trans people in healthcare settings. It costs the RCGP very little to sign a document claiming that they oppose conversion therapy, or condemn the UK government for failing to introduce a legal ban. However, now that the fight against conversion therapy has come to their door, they are not prepared to act.
It is within the power the RCGP to ensure that the CAN-SG conversion therapy is cancelled. They have chosen not to do this. It is within the power of the RCGP to oppose CAN-SG in court, if it came to that. They have chosen not to.
This reflects the same failures we have seen from bodies including NHS England and the Cass Review. I am often asked why trans people do not trust doctors. This is why. We are failed by medical professions over and over again.
That power also potentially lies with you. Trans support groups and harm reduction networks for people self-medicating can be found across the UK, and will always benefit from your support. And you can complain to the RCGP here.
I bounced up to an old friend to share this important insight. All around, queer bodies danced and swayed to furiously enthusiastic music. We have always sought refuge in one another, in our in our art, in utopic dancefloors and community care. But something felt different.
The collective energy of the crowd was wild, strong, cohesive. The entire room was dancing – and among us, so so many out, happy trans women and transfeminine people. On stage, a non-binary person sang explicitly about their experiences of gender to an assertive ska beat. It was a joyful moment – but the true wonder of it for me was that it was far from unique.
This was the last in a string of winter tour dates for my band wormboys, at the brilliant Queer As Punk event in Edinburgh. But I’d experienced similar in Dundee, in Glasgow, in Newcastle, in Hull, in Leeds. At every gig, trans women and non-binary people were scattered throughout the audience; at most, there were also several of us on stage through the night. It’s a world of difference from when I encountered just the occasional trans man playing gigs in the mid-2010s; let alone from when wrote a blog post titled Trans/queer rock musicback in 2010, in which I desperately sought validation in questionable gender-bending tunes written by (largely) cis musicians.
While trans women (and trans people more broadly) have always been involved in DIY music, there’s a clear change taking place. We have taken our inheritance and run with it. There are more of us making our own art, telling our own stories, and celebrating one another more than ever before. We are more visible, we are more assertive, we are more respected within our scenes, and – collectively – we are having more fun.
wormboys play Queer As Punk. Photo by Blanka Bandi.
—
The very night we enacted a better future on that dancefloor in Edinburgh, 16 year-old trans girl Brianna Ghey was stabbed to death in Warrington. Two other teenagers, a girl and a boy, have been charged with her murder.
For trans people across the UK – especially trans women and girls – this lethal attack was not unexpected. It feels like the culmination of a vicious hate campaign that permeates our media and politics. It’s also the tip of a vast iceberg of intentional violence and untimely death.
Suicide is endemic among trans youth driven to despair by the socially-sanctioned antagonism directed at them every hour of every day. I am tired of citing statistics. I have lost so many of my friends and peers. Words and numbers are insufficient for the raw anguish of my grief.
This is only compounded by the failures of bystanders who refuse to intervene, schools and employers who try to make us disappear, a National Health Service that inflicts harm upon us. England’s only child and adolescent gender clinic is due to close in a matter of weeks, with nothing ready to replace it. In an extraordinary open letter, the majority of clinical, research, and administrative staff at the clinic note an “increase in deaths related to the service” since the suspension of endocrine treatments in 2020.
Many of my friends have been threated or assaulted in broad daylight. One, for instance, had rocks thrown at her. Another was assaulted in front of the school gates. Another was raped by boys in the school playground. I frequently struggle with feelings of survivor’s guilt, having merely been publicly assaulted, stalked, harassed, and subject to threats of legal action and murder. Relatively minor matters, in the scheme of things.
Vigil for Brianna Ghey outside the Department of Education, London. Photo by David Griffiths.
—
How to understand joy in the face of so much hate and despair?
This is a question I struggled with throughout our tour. The night before Brianna’s murder, 400 people rioted in Knowsley outside a hotel that houses asylum seekers, spurred on by the fascist group Patriotic Alternative. This horrific event, too, did not occur in a vacuum. Racist and anti-migrant sentiment has similarly been stirred up by cynical politicians and journalists, as asylum seekers, economic migrants, British Black and Asian people, Gypsies and Travellers are repeatedly failed or directly targeted by our authorities and institutions. Patriotic Alternative have also repeatedly targeted LGBTIQ+ communities, through their campaign against Drag Queen Story Hour.
I could say so much more: about assaults on disabled people’s rights and livelihoods, about the demonisation of the poor, about attacks on pay, pensions, and the unions that attempt to defend them (I am writing this post while on strike). About how fascist violence is excused by sexist men in the name of “defending women and girls”. About how oppressed groups are played off against one another, while the effects of all this hateful discourse and action are felt most keenly at the intersection of multiple forms of persecution, such as by migrant trans women of colour.
Ultimately though, my point is this: what we are seeing is both a consequence of historic prejudices in our society, and of rising fascism.
Minority groups, women, migrants, and working class people in the UK have always faced a shared struggle against systemic discrimination and violence. Following a period of mild reform in the 1990s and 2000s, we are now experiencing a significant upswing in bold, blatant hate speech and violence, effectively condoned by every major political party and the majority of mainstream media publications.
This is the context of trans joy in the 2020s – and the reason why that joy is so necessary and vital.
—
Our tour reminded me that art is resistance, and resistance is collective. In recent days I have felt myself marinading in my own fear, a recipe for passive inaction. If we cannot experience joy, we cannot dream; if we cannot dream, we cannot hope; if we cannot hope, we cannot fight back. In the face of a world that wants so many of us dead, it is vital that we create reasons to live, and to thrive.
In Leeds, wormboys played to a rammed room in Wharf Chambers, a triumphant hometown crowd. We invited the brilliant Punjabi-Celtic-indie fusion trio Kinaara and gorgeous queer folk duo Serinto support us, building new friendships and cementing old ones. In Hull we debuted at the New Adelphi, where now-legendary acts such as Lizzo, Manic Street Preachers, Pulp, Skunk Anansie, and PJ Harvey played before they were famous. We shared the stage with Sandbox Mode – a solo hip-hop artist making deeply honest and funny songs about mundanity and despair – and Baby Flowers, an exciting young grunge group playing their second ever gig. This was the least well-attended, most male-dominated, and least obviously queer gig on our tour. And yet: the mood was vibrant, I noted at least one other trans woman in the audience, and Baby Flowers’ bassist was showing off a well-placed trans rights sticker.
In Newcastle, we found ourselves in the Little Buildings, a venue which has miraculously survived Covid-19 despite being founded just the pandemic began. The event was hosted by new dance party Queer Love. We played alongside the incredible hardcore group Disciplinary with their two bass guitars, and also the feminist dance-punk phenomenon of Fashion Tips. The whole night was amazing, but Fashion Tips were particularly exciting for me. Frontwoman (and Queer Love organiser) Esmé Louise Newman has a long history of involvement in groundbreaking queer feminist punk, metal and no-wave groups, including Penance Stareand Etai Keshiki. The new band were just as brilliant, with aggressive guitars and vocals underpinned by a powerful rhythm section, heralding a new era of revolutionary dancefloor divination.
Next to Glasgow, where I organised a well-attended gig at The 13th Note in less than a week, after our original promoter pulled out at the last minute. We booked the astoundingly powerful riot grrrl group Brat Covento play with us, along with HAVR, purveyors of gorgeous post-punk soundscapes. The latter band are fronted by Carrie Marshall, author of Carrie Kills A Man, who noted to cheers that she was a different gender the last time she played the venue. This was an event with plenty of trans women present, beaten only by brilliant gig in the same venue the very next night, which I went to see my soulful dyke folk pal Pictureskew play inbetween our own shows. That event might well be the first of its kind I’ve been to where there were at least as many trans women in attendance as anyone else. It was beautiful.
Then to Dundee, where Rad Apples and Make That A Takeput anarchist theory into practice by actively working to provide a safer punk venue and events for women, queer people, and migrants, through simultaneously building a welcoming space and promoting a zero-tolerance attitude towards discrimination and abuse. There I had two totally new life experiences. First, I witnessed somebody crowdsurfing in a shopping trolley during a storming set from banjo punks Alldeepends. Then, we were subject to the well-organised chaos of the “crowd surfing machine” by jubilant anarcho-folk headliners Boom Boom Racoon (a variant on the sat-on-the-floor rowing boat dance associated with songs such as “Oops Upside Your Head” and “Rock The Boat”, but with audience members encouraged to take turns in crowdsurfing along the boat).
Through the tour, I’d been carrying a trans flag to drape over my bass amp, and have often said something about trans liberation from stage inbetween songs. wormboys are a political band, but not in the same way as more in-your-face punk groups I’ve previouslyfronted. I’ve reveled in the ability to just be a musician and make that – rather than my status as a trans woman – the focal point of my involvement, leaving most of the talking to dual vocalists duo Sop and Harry. In the current political environment, that has increasingly felt untenable. It seems important to speak out, make myself visible, be obviously a trans woman making music.
But at Rad Apples I didn’t need to. There was already a trans flag up. There were plenty of other trans people there. There were placards in the bar opposing Section 35. I could just be.
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And so to Edinburgh, where I found myself living in the future during a joyous set from opening act Bufandas. A future in which we experience the true paradox of trans visibility, in that we are both uniquely vulnerable, and uniquely strong. No longer hiding in the shadows, we are easier targets for those who hate us, but also have so much more potential to build power together.
Brianna Ghey’s killers may be convicted and jailed, but that will do nothing to stop the violence we face across these islands, and across the wider world. We have learned that we cannot trust the police to save us, or the courts, or politicians, or journalists, or managers, or human resources departments. But we don’t need any of these people or organisations. We owe it to Brianna to continue the grassroots work she did to improve other people’s lives, because another world is possible.
The headliners at Queer as Punk in Edinburgh were the fiercely feminist disco punk group The Red Stains. Their set included several explicit statements of support for trans people and especially trans women and girls, reflecting the attitude of most women active within actual feminist movements. This was an important reminder that anti-trans movements do not speak for all women, and never will.
My experience of sharing a stage with so many amazing musicians, from so many backgrounds, featured many such reminders. I was reminded of the sheer depth and range of human creativity. I was reminded of how much we can be inspired by our differences as well as shared experience. I was reminded of how far we have come, as well as how far we have to go.
There are so many of us. Today, we mourn. Tomorrow, we fight. Soon, we will win.
A couple of days ago I joined Katy Montgomerie’s livestream to work through the current NHS England consultation on child and adolescent gender services. We discussed the background to the consultation, what the questions mean, and what some of the major issues are.
You can take part in the consultation here. It is open until 4th December 2022. Filling it in is a bit of an intense experience, but if you fancy some friendly company and catty cameos, I hope our video will help.
Three weeks ago, I wrote to the NHS England Gender Programme Board (of which I am a former “patient public voice” member) to raise urgent concerns about their consultation on a new interim service specification for children and adolescents.
The proposed service specification is deeply transphobic on numerous levels – from the dearth of relevant treatment pathways, to the assertion that being trans is likely a “phase”.
It is also probable that if implemented, this service specification will impact other young people more widely – especially girls and LGBTIQ+ youth – by undermining principles of autonomy and respect.
The consultation is open to anyone. If you have the time and energy, there is a guide to participating in the consultation here, prepared jointly by Gendered Intelligence, Stonewall, Mermaids, and the Trans Learning Partnership. If you are a community member, a healthcare practitioner, a researcher, or work with a relevant charity, it would be particularly useful for NHS England to hear from you.
Other things you could do to oppose the proposals include: organising a demonstration, raising awareness of this issue on social media, and/or writing to your MP or trade union and asking them to place pressure on NHS England to reconsider.
To date, I have not received a reply from NHS England. Given the danger the proposed service specification poses to the safety of young people, I have now decided to make my letter to them public.
~
Dear all,
I am emailing to share my great alarm at the proposed service specifications for child and adolescent gender dysphoria services. It is my expert opinion that, if implemented, these proposals will cause great harm to young people. Moreover, in opening such poorly designed and unevidenced specifications to consultation and media commentary, NHS England has already caused harm.
The fact that this consultation is happening at all represents an enormous failure on the part of every professional involved.
I stepped down from the Gender Programme Board earlier this month due to clashes with my teaching schedule. However, given the severity of this situation, I would be remiss in my ethical duties if I did not also email you directly to share my concerns.
My three main areas of concern are:
Social transition should not be subject to medical oversight. This would represent a gross abuse of power on the part of commissioners and practitioners. Choosing to wear different clothes, and possibly use a different name and/or pronouns – is a personal, non-medical decision related to a person exploring their identity and/or coming out. Preventing a young person from choosing a social transition amounts to an attempted conversion practice.
Punishing young people and their families by subjecting them to investigation if they access private services will not help them access healthcare. Young trans people who access private healthcare in the UK or abroad generally due so due to the severity of NHS failures. It will increase the likelihood of young people hiding the fact they are accessing external treatment from NHS clinicians, and of people turning to black-market hormone providers rather than private doctors. I am not sure that members of the Gender Programme Board are fully aware of how prevalent and dangerous the home-made substances already in circulation can be.
Requiring that young people become research subjects as a condition of accessing treatment is completely unethical. This is a well-established principle in the trans health literature. There is no way in which you can truly obtain informed consent for research participation from individuals who will be denied healthcare if they refuse to participate. I fully support the expansion of NHS-funded research into trans healthcare, but participants must not be recruited through coercion.
I will end by inviting all recipients of this email to reflect on what they do not experience, and what they do not know.
Most members of the Gender Programme Board have not experienced gender incongruence or gender dysphoria.
Most members of the Gender Programme Board are not members of a trans community. It is likely therefore that you – even if you are a clinician – have never found yourself in a position where you are confronted with the true impact of NHS failings on young trans people who rely on community support. You do not know what it is like to be trying to look after many extremely damaged members of your community dealing with complex trauma and self-harm from people who have been repeatedly abused by NHS clinicians and processes. We, in the community, are the ones left picking up the pieces of your failings, finding ourselves on constant suicide watch and scrabbling to keep people alive. Invitations onto bodies such as the Gender Programme Board, where we are expected to be polite while fighting for scraps – only to be ignored – do not right these overwhelming wrongs.
My book Understanding Trans Health is cited prominently in the new Philosophy Tube video on complaint, systematic inflexibility, and England’s NHS trans health crisis.
It’s a great video, which manages to capture the sheer horror of NHS failings while still delivering silly jokes, ridiculous costumes, and a strong analysis. In addition to drawing on my work, Philosophy Tube’s Abigail Thorne consulted me on the script for this episode, and I appreciated the opportunity to use my research in this way.
I am personally more optimistic than Abigail about the opportunities offered by the four NHS England ‘pilot’ clinics. These are beginning to slash waiting times, and several are now effectively run by trans people, for trans people. However, I do think it’s important to still critique the very logic that underpins many trans healthcare systems, especially the highly questionable ways in which the medical diagnosis of ‘gender dysphoria’ is constructed, and used to try and control us.
You can buy Understanding Trans Health directly from Policy Press here. It’s also available from all major booksellers, plus many independent queer book stores (e.g. Leeds’ brilliant The Bookish Type). I have also written to my publisher for permission to put a chapter of the book online for free – watch this space! In the meantime, free links to much of my other academic writing can be found here.
Dr Ruth Pearce 