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The British government is throwing young trans people under the bus

Following the publication of the Cass Review, it’s going to be harder than ever for young people to access gender-affirming care in Britain

The Cass Review – a report looking at children’s gender-related care in the NHS, which was published yesterday – has been welcomed warmly by the anti-trans press, the Tories, and Labour’s shadow health secretary, Wes Streeting. But for trans young people, it represents the latest in a long string of attacks on their autonomy, and their right to make decisions about their own lives. 

The review recommends that the NHS adopts a wide-ranging system of assessment and mental health treatment, with no provision of puberty blockers without enrollment in a clinical trial, and extremely limited access to cross-sex hormones before the age of 18. One of the reasons for the Gender Identity Development Services’ (GIDS) years-long waiting lists – which have made gender-affirming care already out-of-reach for the vast majority of young trans people – was the requirement for two clinicians to attend every appointment. The Cass Review proposes an even more resource-intensive approach, that may exacerbate the existing bottleneck of referrals, if it doesn’t drive trans young people away from the NHS altogether.

The therapy-based approach encourages patients to consider alternative reasons for their gender-related distress, often eating disorders, neurodivergence, or social acceptance (as if being trans makes you popular at school) – all of which must be carefully worked through before medical transition can be considered.

The model offers all the harm of conversion therapy, with the convenient excuse that transition may be considered if all other avenues have been exhausted. Dr Hilary Cass acknowledges that some young people will need medical intervention, but in presuming that the majority will not, and that it should be avoided at all costs, Cass appears to be endorsing conversion practices on a mass scale.

The review even starts from a false premise. “We have no good evidence on the long-term outcomes of interventions to manage gender-related distress,” it proclaims in the introduction. But puberty blockers and cross-sex hormones are better at alleviating distress than Cass claims, not least because she has chosen to exclude the majority of potentially relevant studies from her review.

But there is a greater underlying falsehood. Since 2019, the World Health Organisation has recognised that “trans-related and gender diverse identities are not conditions of mental ill-health, and that classifying them as such can cause enormous stigma.” Dr Cass, while noting this, opts to resurrect the framework of gender dysphoria, treating transition as a worthwhile endeavour only if it alleviates mental health issues. 

But transition is not a mental health issue – it is a decision which requires medical assistance to realise and which medical practitioners facilitate (another example being pregnancy in people who cannot conceive naturally). There will never be a scientific way of ensuring that a trans boy sitting before a clinical psychologist and asking them to let him take testosterone will not come to regret this decision as an adult, though studies suggest exceptionally low rates of regret among children who do have access to transition. The error is in suggesting that the boy should not access testosterone unless this can be definitively determined. 

The Cass Review imagines that, with further study, the NHS will finally find the exact combination of sexual orientation, toy preferences in childhood, and pornography consumption habits in adolescence that will reliably predict whether that boy will become a trans man or a cis woman. To this end, Cass obsesses over growing the collection of data. After being ‘thwarted’ in her attempts to force adult gender clinics to hand over patient records, Cass is calling on the government to compel this same violation of patient privacy. Submitting to study will also be a prerequisite to receiving puberty blockers on the NHS.

The needs of clinicians, who are scared to treat this patient cohort whose healthcare has been so politicised, and parents, whose consent must be obtained for a treatment plan to commence, are treated as the most important thing. The needs of the patients themselves, who Cass consistently misgenders, and whose wishes she repeatedly and explicitly rejects in her report, are some way down the list. It appears never to occur to Cass that some transfeminine people have no interest in vaginoplasty, some nonbinary people may want surgery, or hormones, or both, and some trans people prefer physical intervention before social transition, often for their safety.

The fact that over 40 per cent of trans people in the UK experience abuse from family members merits no discussion, despite Cass’ proposed assessment model allowing parents to provide a history of their child’s gender. Cass also recommends, likely taking cues from anti-trans parents’ groups, that the youth gender service integrates care for 17 to 25-year-olds, medically infantilising the 75 per cent of adult gender clinic patients in this age group. It remains unclear if GIDS’ ludicrous practice of forcing 17-year-olds to bring their parents to appointments – which doesn’t apply in any other field of medicine – will be extended into patients’ mid-twenties.

Worst of all, the consent and comfort of the people this service is meant to be for is an afterthought. Cass notes it is disappointing that many young people felt the need to lie to their GIDS clinicians about their mental health, but proposes nothing that would restore trust in the new service. Social transition – which consists of changes to names, pronouns, dress, and hairstyles – being treated as a clinical intervention works to insert the NHS into the lives of trans toddlers and primary school-age children, cautioning parents against allowing them ‘go stealth’ (i.e. live fully in their chosen gender) because of the pressure it may later exert on medical practitioners to prescribe them puberty blockers.

Cass believes it would be unethical to move to the informed consent model that the vast majority of trans people support, and is instead pushing for a medical system that places far too much responsibility on practitioners to divine potential regret, which leads clinicians to serve a misguided professional ethic rather than the patient sitting in front of them. 

The report’s recommendations are an all-out assault on the dignity and lives of trans children and young adults, whose existence presents a threat to the medical orthodoxy that “doctors know best”. Cass may push trans healthcare underground, but trans people will always stand up and fight back.

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