Dr. Hilary Cass, a senior paediatrician, has released her final review of gender identity services for NHS England. This follows on directly from a groundbreaking judicial review of the Tavistock Gender Identity Development Service (GIDS) in 2020, brought by Keira Bell, a detransitioner (Jenkins, 2021). This crucial legal case triggered the decision to close down the GIDS in 2024 and move to a more holistic model of assessment and treatment for gender distressed children under 18. Peter Jenkins offers a provisional appraisal of the Review below.
Balance sheet of the Cass Review
Judging by the huge surge in media interest in this contested topic, the Cass review marks a watershed moment in the long-suppressed debate over the ongoing medicalisation of children with gender distress. Even long-captured media outposts, such as the Guardian and the BBC, have been forced to acknowledge the weak evidence base for medical interventions such as puberty blockers (now all but banned by the NHS) and the collapse of medical safeguards in the headlong rush to get kids on treatment. Other establishment media, such as The Times and Telegraph, are clearly enjoying the opportunity to publish a backlog of critical material, taking the NHS and its gender ideologues severely to task.
Positive elements of Cass Review and underlying problems
There are many positive aspects to Cass, not least that it enjoys the implicit support of both major parties and is likely to have some real traction in terms of likely reforms. The review rebalances treatment of gender distress away from medicalisation and back towards less invasive methods, such as psychological interventions. It reasserts the need for a clear evidence base for any treatment, preferably via systematic reviews, and takes down, bit by bit, the unwarranted influence of organisations like the World Professional Association for Transgender Health (WPATH). It picks a careful path between the clash between gender affirmative therapy and exploratory therapy, but then openly recognises the need for proper exploration of children’s complex mental health concerns. It fully acknowledges that the client group seeking treatment are overwhelmingly gay, lesbian or bisexual. Safeguarding issues, frequently sidelined at the GIDS, are reasserted. The distinct needs of detransitioners, long neglected, denied or just plain ignored, are put back firmly on the agenda again. So, there is much of value to celebrate in the review.
The problems with Cass are really inherent in the nature of trying to deal with a deep-seated political conflict, by relying largely on a policy change to shift the blockage. The debacle at the GIDS is just one expression of the growth of gender ideology and its increasingly divisive authority at all levels of society. Gender ideology represents a powerful fusion of post-modernist rejection of science and reason, a demographic challenge to sexual norms and behaviour, and a captured and repurposed model of human rights, all of which are fuelled by adroit use of social media networking and backed by wider techno-pharmacological interests.
Fragility and exceptionalism
At one level, Cass shows some grasp of this intimidating reality. Critics of gender ideology in the field of therapy have pointed to gender ideology’s reliance on the twin concepts of trans fragility (e.g. claimed heightened risk of suicide, minority stress), which, in turn justifies trans exceptionalism (use of preferred pronouns, queering therapy boundaries, soft-pedalling on safeguarding, etc). In terms of trans fragility, Cass finds little data to support the standard claims for heightened suicide risk, which tend in any case to be confounded by co-morbid risk factors, such as autism, depression, abuse and anxiety. Also, Cass directly acknowledges that “this group of young people have been exceptionalised”, i.e. treated differently, but without any clear supporting rationale (Cass, 2024: 13: emphasis added: PJ). At certain key points, however, there is a seeming failure by the review to follow through the logic of its own argument. Hence, on the key developing battleground of social transition, particularly in schools, Cass falls back on pointing out the lack of definitive research findings, but then drops the ball. This is a jarring comparison with the similar lack of definitive research of proven benefit and evidence of potential harm for puberty blockers, which, in sharp contrast, led to them effectively being banned by the NHS.
The continued strength of this ideological faction is suggested by the way that the Tavistock GIDS has resisted any effective accountability for its actions, save for the legal route via Keira Bell’s judicial review. It is also apparent in the apparent sabotage by adult gender clinics in the NHS of data sharing essential to wider research and effective clinical governance. The clear risk is that the internal conflict generated within the GIDS will now be replicated within the proposed regional hubs for children (Stock, 2023). Reforming gender services within the NHS will prove a daunting task for any government, given the ideological capture across the whole of civil society, namely schools, universities, NGO’s, trade unions, professional associations, regulatory bodies and certainly the NHS itself.
A medical service for an identity issue?
Despite the many overall positives to be found in the Cass Review, there remains an ultimately fatal irony about its underlying premise, in reviewing a gender identity development service for children, or for adults, or even for anybody at all. A gender identity service could perhaps survive when it was a niche, highly specialist service, tucked away in a prestigious institute, serving a tiny cohort of atypical clients (Di Ceglie, 2021). The recent unrelenting blast of publicity, however, must have led at least some observers to wonder how can a medical service be provided for a fundamentally psychological condition?
The bedrock concept of gender identity has no widely agreed or testable criteria. It can only be defined by totally circular reasoning, usually consisting of some combination of the terms ‘identity’ and ‘gender’. It sits within a pre-scientific cultural belief system, and depends on social validation by others for its continued existence. Stock raises the provocative analogy of trepanning, as cure for demons, as some kind of exemplar (Stock, 2024). Other unsettling parallels might be found in terms of clitoridectomy for hysteria in the nineteenth century, or frontal lobe lobotomy for obsessional personality in the 1960’s. So, how can medical means be used with any confidence to treat a psychological condition with no agreed definition, or established criteria, which is ultimately reliant on self-diagnosis?
Challenging the concept of a gender identity
It might be unfair to ask the Cass Review to address this fundamental, almost existential, question. After all, Cass is unlikely to challenge the foundational concept of gender identity itself. This might be the equivalent of sawing off the same branch of the tree one was carefully perched upon. But it does bring into question the role of therapy and psychological support within this wider enterprise. Is therapy being promoted here as a viable alternative to medical transition for people with gender distress? Or is it to help narrow down the selection process for medical treatment? In a recent interview, Cass makes the following statement:
“Psychological therapy is not about changing people’s minds about their gender. It has been made synonymous with conversion therapy. It’s about getting young people into the most robust state of mental health to go through medical transition, if that is what they want” (Abassi, 2024: 1: Emphasis added: PJ).
So, Cass Review or no, medical transition remains on the table for a self-diagnosed psychological condition, with no testable criteria, or agreed definition.
Conclusion
Given the crushing weight of contradictory expectations, the Cass Review was probably destined to disappoint everyone at some level. It does mark the high tide level of an encroaching wave of gender ideology within the NHS, and hopefully, the slow ebbing away of the latter’s success in setting the terms of practice and policy on treatment of gender distress within England. With the exception of its unhelpful dithering over social transition, there is much to celebrate in terms of its clarity and careful reasoning. Its findings will, no doubt, continue to reverberate down the corridors of power for a long time to come.
References
Abassi, K. (2024) “Medication is binary, but gender expressions are often not: The Hilary Cass interview”. British Medical Journal. 9 April 2024. https://www.bmj.com/content/385/bmj.q794
Cass, H. (2024) Independent review of gender identity services for children and young people. Final Report – Cass Review
Di Ceglie, D. (2021) “The creation of a service for children and adolescents facing gender identity issues”, pp. 159-164, In M. Waddell and S. Kraemer, (Eds) The Tavistock Century: 2020 Vision. Bicester: Phoenix.
Jenkins, P. (2021) Calibrating Gillick in the age of gender wars: Part 2: The curious case of the Tavistock. Critical Therapy Antidote: Calibrating Gillick* in the Age of Gender Wars: Part 2: The Curious Case of the Tavistock – Critical Therapy Antidote
Stock, K. (2023) “Inside Britain’s new trans clinics”, Unherd. 19th October. Inside Britain’s new trans clinics – UnHerd
Stock, K. (2024) “How a cult captured the NHS”, Unherd, 12th April. How a cult captured the NHS – UnHerd
Commentary by Peter Jenkins, a member of Thoughtful Therapists, whose scoping survey for the UK government consultation on conversion therapy can be found here: https://thoughtfultherapists.org/scoping-survey-pdf/
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