Commentary on Political Economy

Saturday 13 April 2024


Cass was a skirmish, now prepare for a war

The Times

The Cass review is a diligent, extensive piece of research conducted over four unhurried years by a distinguished paediatrician and her crack University of York team. It puts under surgical scrutiny every tenet of child gender medicine and finds the evidence that underpins it gravely flawed. Yet as Dr Hilary Cass herself notes, the review had one failure.

Imagine if 9,000 children who began treatment at the Tavistock Gids clinic (the NHS Gender Identity Development Service) were interviewed as adults. How did their lives pan out? What proportion are thriving as trans? How many now regret their youthful decisions? Has their mental health improved? Is their physical health affected by hormones? How many detransitioned, and why? A longitudinal study of this size would benefit not just NHS England but gender medicine worldwide.

Surely anyone who cares about these troubled adolescents, two thirds teenage girls, would leap to assist. The study’s key barrier, that a trans person acquires a new NHS number making it impossible to link a female child to an adult with a male gender marker, had been removed by special legislation for the purposes of the review.

So the flat refusal by six out of seven adult clinics to participate is the most revealing thing in Cass. The Nottingham clinic head, Dr Derek Glidden, wouldn’t comply despite being the NHS’s most senior adviser on trans health. Relations between the adult service and the University of York team grew so hostile, meetings were abandoned. And in this we see future problems for implementing Cass’s recommendations: that was just one skirmish; what lies ahead is a war.

Gender medicine is hugely suspicious of data. Clinics are noted for professional incuriosity and institutional sloppiness. I recall judges at the Keira Bell judicial review flabbergasted by Gids’s derelict record keeping. So no wonder they feared what Cass’s researchers might find. Even without the adult data, Cass coolly blew apart everything from suicide myths to the claimed benefit of social transition. With the data, what might she have found? Perhaps detransition rates far higher than the claimed 1 per cent, or that female misery is unalleviated by amputated breasts. Then the whole clinical edifice might crumble — which it still could, now adult services face their own independent review.


The broader truth is that child gender medicine is not fuelled by science but activism; not upon “does it work?” but “does the patient demand it?” Poor data is not a glitch but a feature. As the British Medical Journal’s editor-in-chief, Kamran Abbasi, notes, studies in this field “fall woefully short in terms of methodological rigour”. Low-grade studies, where a conclusion is easier to influence, are what gender activists prefer. And because Cass disregarded such studies that fail basic hurdles (like having a control group), the activists now damn her work as methodologically flawed.

How do you create a new evidence-based service still staffed by clinicians who abhor evidence? The very Gids therapists and psychiatrists who oversaw a medical scandal, expediting children to blockers and hormones, still work in this field. They post on social media groups about how their work was misunderstood and that, as pariahs, they’re the real victims.

How can they fall in line with Cass when they disagree on first principles: ie does a “trans child” exist? Cass’s position tilts towards trans identity being socially constructed, peer-influenced or, in girls, spurred by a fleeing from womanhood precipitated by sexual abuse or porn. But gender ideologues believe an infant contains an innate gender identity that is apparent from early childhood, and the clinician’s job is to help manifest it, by bodily mutilations if required.

Cass seeks a new model of “holistic care” from a broad team, including autism experts and social workers, which considers mental health issues, family pressures and sexuality to see a child’s life in the round. Ex-Gids staff believe that only gender specialists can truly understand “trans kids”, and it is transphobic to investigate external causes. Cass wants a cautious, continuity service for 17 to 24-year-olds that acknowledges their development is still in flux; gender ideologues cry that this is infantilising.

Who will ensure Cass’s principles of holistic, open-minded neutrality are kept, given so many gender clinicians transitioned themselves? (Some clinics advertise as being “trans and non-binary led”.) Especially when gender care will be spread over several regional centres, with greater room for clinicians to sabotage new guidelines by stealth. Stonewall and Mermaids, who evangelised about puberty blockers, now bizarrely claim Cass’s views were theirs all along. But are they keeping a low profile while they work out new back channels to activist clinicians?


In a cash-strapped NHS where child mental health is on the verge of collapse, Cass’s ideas seem utopian. They rest on strong NHS management and resolve from a new Labour government. Wes Streeting, the shadow health secretary, who had a late gender-critical conversion, has said Labour will implement Cass in full. As a gay man, an ex-Stonewall staffer no less, he has strong political capital. But if Labour has a super-majority, its de facto opposition is the left, wherein lie many who reject Cass. Already Dr Cass has met Kemi Badenoch, the equality minister, to say a conversion therapy bill, which has some cross-party support, would inhibit full, open discussion of gender identity and thwart her new service. Labour is packed with LGBT ideologues such as Angela Eagle, who would gleefully do so.

The Cass review is a magnificent achievement yet no cause for celebration: too many young people have suffered who now deserve treatment founded upon science and reason. But implementing that within an ideologically riven NHS will require a new Enlightenment.

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