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Artillery Row

Correcting Cass’s critics

Attempts to intellectually discredit the Cass Review have completely failed

Last week the long awaited Cass Review (The Independent Review of Gender Identity Services for Children and Young People, to give its full title) was released after more than 3 years of work by paediatrician Hilary Cass. 

Over 388 pages, the report lays out what’s known about the field of youth gender medicine and makes a series of recommendations that have already changed how children are treated in the NHS. In an area riddled with misinformation and toxicity, it’s a blessed relief to read something thoughtful and evidence based. 

The conclusions of the report, though couched in sober non-sensationalist terms, are nevertheless striking. “The care of these children and young people came to deviate from usual NHS practice” Cass found. Instead of providing treatments based on reliable research, “clinical practice became disconnected from the clinical evidence base” as children were routinely offered treatments that had never been properly evaluated.

The problems stem from the ideological “affirmative model” pushed by activists — the idea that the only acceptable response to a child wanting to transition is to allow (indeed encourage) them to do whatever they wish to their bodies. Too many in the NHS uncritically adopted this model (as has happened in other health services — not least in the US). Cass, however, starts as all scientists should from an open minded position. She asks what’s the best way to help young people with gender issues to “thrive and achieve their life goals”? Having spent years looking at the evidence she finds that “For most young people, a medical pathway will not be the best way to manage their gender-related distress”. The affirmation model dismisses the possibility that a child being trans could ever be a phase that passes with time — but Cass finds that even a confirmed diagnosis of gender dysphoria “is not reliably predictive of whether that young person will have long standing gender incongruence in the future, or whether medical intervention will be the best option for them.” 

What the studies did find was evidence of harm

On the crucial question of whether puberty blockers, which have been given to hundreds of children on the NHS, actually do any good — the report says the evidence is sorely lacking: “no changes in gender dysphoria or body satisfaction were demonstrated. There was insufficient/inconsistent evidence about the effects of puberty suppression on psychological or psychosocial wellbeing, cognitive development, cardio-metabolic risk or fertility.”

What the studies did find was evidence of harm: “Multiple studies included in the systematic review of puberty suppression found that bone density is compromised during puberty suppression, and height gain may lag behind that seen in other adolescents.” And perhaps even more concerningly, Cass concluded “brain maturation may be temporarily or permanently disrupted by the use of puberty blockers, which could have a significant impact on the young person’s ability to make complex risk-laden decisions, as well as having possible longer-term neuropsychological consequences.” The NHS has already taken action on the basis of these conclusions, stopping all future use of puberty blockers for under 18-year olds outside of an experimental research protocol.

Given that the report radically reshapes gender youth medicine in the UK (and will likely have significant influence beyond), it’s been fascinating to see the reactions. Perhaps the most important response was from the Labour Party (since almost everyone believes they’re going to be in power in the near future). Wes Streeting MP, Shadow Secretary of State for Health, was unequivocal in his support for Cass calling the report “thoughtful and thorough” and pledging to implement all its recommendations. Perhaps more surprising was Stonewall — a charity which had previously called for material that questioned the affirmative model to be shredded — who now praised the Cass Review for its “positive impact”  towards the goal of quality trans healthcare: “The Cass Review can play a vital role in achieving this aim, if its recommendations are implemented properly”. Stonewall didn’t want this document shredded but rather said: “We urge NHS England and policymakers to read and digest the full report…”

One might be forgiven for thinking that Cass had achieved the impossible, bringing this particularly nasty war of words to an end and ushering in a new era where evidence rather than insult was the guiding light. Sadly not.

Before the report had even been released, activists had decided it was flawed, biased and part of a conspiracy to erase trans people. This culminated in an open letter seemingly signed by over 200 academics blasting the Cass Report for its shoddy methodology and harmful conclusions.  

The letter appears to be damning. Hilary Cass OBE might be one of the most distinguished paediatricians in the country — a former president of the Royal College of Paediatrics and Child Health — but according to the authors of the letter her report is “shoddy in the extreme” and “would fail if it were submitted as an undergraduate dissertation”. You don’t need to be an academic to know that that’s quite the insult.

Now I don’t generally like appeals to authority — but the authors of the letter do claim to be “experts in the field” and boast of “decades of research experience between us” (perhaps not the most impressive claim given over 200 signatories) so it seems fair to examine whether they really are more credible than the distinguished scientist they are attacking. They do include academics and even Professors from some very prestigious universities — but also more humble folk such as Dominique Bailey who self-describes as a “Human Being With Morals”. However, when you look into their areas of expertise, you find marketing, and media studies better represented than medicine. Perhaps unsurprisingly, gender studies and experts in LGBTQIA+ communities make up a large proportion of the signatories. There’s nothing wrong with these subjects, and should I be seeking an expert on “Anti-Dualist Cosmopolitanism” or the films of Shane Meadows the list will be most helpful. But if I’m looking for an assessment of the evidence on paediatric medicine I would think an experienced paediatrician might be more reliable than an expert on contemporary literature.

Unfortunately for those criticising Cass for her sloppiness, the letter has some methodological problems of its own

Nevertheless, we should consider their letter on its merits. If Cass really is guilty of producing an “inadequate piece of research” with a methodology that is “shoddy in the extreme” that’s an important thing to know. Unfortunately for those criticising Cass for her sloppiness, the letter has some methodological problems of its own. For one thing, the online form which you use to sign the letter  has different text from the version that appears on their blog, so it’s not clear which version of the letter people have actually signed up to. 

The published letter has helpfully numbered the signatures so you can see how many supporters it has — but without bothering to remove duplicates. Dr SJ Pattison (retired) is so keen that they’ve signed it three times! It does take some chutzpah to criticise a fellow academic for sloppy work when you’re unable to accurately count to 200. Some of the signatories have proven particularly controversial. For instance, at one point Dr Andrew Wakefield (the disgraced anti-vaxxer) appeared on the list — though his name has now been removed. Was he a genuine supporter or was his name added as a hoax? Neither possibility gives one great faith in the rigour of this exercise.

Of course, what really matters is the substance of their critique. On what basis do they claim that the Cass Report is unsound? Here the letter moves from sloppiness to outright falsehood. The letter claims the report “does not include a proper systematic literature review”. In fact the report includes 6 systematic reviews plus additional evidence surveys, published across 9 peer-reviewed journal articles. These were carried out using well established methods and multiple independent reviewers. The only reason the critics reject these reviews is because they don’t like the conclusion.

An even more egregious lie is that the Cass report excluded any research that doesn’t meet “the impossibly high bar of a double-blind trial”. This has now become a standard line of attack by activists keen to rubbish the report. It’s simply untrue. The Cass Report does provide a brief overview of the different types of evidence and correctly states that blinding is often used in research to avoid the placebo effect. Such trials represent the gold standard of medical evidence — but sadly no such research has ever been carried out in this field. That doesn’t stop Cass considering the research which has been done. In its review of the evidence, the Cass report includes 60 studies (26 on puberty blockers and 34 on hormone treatment) even though none of them are double-blind trials. It’s true that a number of other trials were considered of such poor quality that they were excluded from the analysis — of the 103 studies they examined 58 per cent were included and 42 per cent excluded. This is standard practice in reviews of medical evidence and the exclusion of low quality research means we can be more confident in the reports findings, not less.

Yet the falsehood — that Cass ignored 98 per cent of the research available because it wasn’t double-blind — is spreading through social media and being treated by many as fact. A similar false claim was made by Dawn Butler MP in the House of Commons. (Butler has previous form on this topic famously stating that a child is born without sex.) These are deliberate attempts to smear the Cass report with misinformation and it’s shameful that people in positions of power and influence are spreading it when they clearly haven’t read a word of the report.

Lastly, the letter claims that Cass fails to include trans peoples’ voices. Yet the review team met and listened to over 1000 people prioritising those with direct personal involvement in the issue. They held weekly listening sessions “to hear directly from people with primary lived experience (individuals who identify as transgender, non-binary, gender fluid and/or who have been through a period of gender-questioning)”. Many of the Cass recommendations stem directly from those lived experiences. Yet because Cass dared to also hear from people who disagree with the ideology of total affirmation, she’s accused of “presenting anti-trans campaigners’ rhetoric”.

What the letter does is perfectly illustrate how we got into this mess — where potentially harmful drugs were given to vulnerable children with no good evidence of their effectiveness. Cass talks of the poisonous atmosphere surrounding this topic — “the toxicity of the debate is exceptional” she says in the foreword. She’s careful to point out that there are abusive voices on both sides — and anyone who has spent any time on twitter will know that’s true. Yet that even-handed introduction doesn’t tell the whole story, and in the body of the report it’s clear that the pressure that led to ideology triumphing over evidence came almost entirely from one side. There are parents who “felt ‘forced’ to affirm their child’s assumed identity or risk being painted as Transphobic”, GPs and clinicians “under pressure to support a medical pathway based on widespread reporting that gender-affirming treatment reduces suicide risk.” even though the scientific evidence didn’t support that claim.

The vicious silencing of voices who raised the very concerns now vindicated by Cass has been going on for years, driven not just by internet trolls (who, yes, can be found on both sides) but by powerful organisations, mass campaigns of harassment and even by professional bodies. Just last month a conference for doctors to discuss youth gender medicine was attacked by aggressive masked protestors. There have been no comparable attempts to silence those in favour of the affirmation model. 

This letter is just another attempt to smear and bully those who dare to disagree with gender identity ideology. Of course there’s nothing wrong with disagreeing with the reports conclusions based on evidence and rational argument — but to do so requires actually reading and understanding the report, something I’m confident few of the signatories have done. 

Fortunately, Hilary Cass has shown herself to be quite able to stand up to the bullies. Faced with such a clear evidence-based review, the activists’ insults ring hollow. Even Stonewall seems to know the game is up. The few who still insist on putting ideology before evidence only embarrass themselves. The letter is now a handy list of those who place so little value in academic standards that they’ll throw juvenile slurs at the work of a distinguished expert just to prop up their political views. This is a list of shame.

But we must never forget that this report is about children and young people who have been failed because the processes that are supposed to ensure safe and effective medicine were ignored. “This is an area of remarkably weak evidence … research has let us all down.” Cass says. The real shame is for those that allowed that to happen.

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