Sunset Boulevard Part 1

Update 347 Cass Review Special

OK, dear readers, I am splitting this update into two. Part 1 deals, of course, with the Cass Review and Part 2 deals with other things. But before we get to that, we obviously need No 21 in the Leading Female Season and this is indirectly thanks to Andrew Doyle, namely Gloria Swanson in Sunset Boulevard.

Gloria Swanson is Norma Desmond and William Holden is struggling screenwriter, Joe Gillis. Joe is trying to interest Paramount Pictures in a story he submitted. While fleeing from repo men seeking his car, Joe turns into the driveway of a seemingly deserted mansion inhabited by forgotten silent film star, Norma Desmond.

Thanks to two wonderful readers for suggested pieces.

The Cass Report

The Review is here:

https://cass.independent-review.uk/wp-content/uploads/2024/04/CassReview_Final.pdf

I appreciate that many if not most of you will not have the time to read a 388 page report. Firstly, I recommend at least just reading the Summary and Recommendations. Then I have compiled for you below articles, blogs and videos which will help you see what others are saying about it.

I agree with Kellie-Jay Keen ( you need to watch both of her videos below) that this is wonderful and a turning of the corner but does not go nearly far enough. I also agree with KJK that the conclusion of the report should have been that this is one of the biggest medical scandals we have ever seen.

I hope that the continued repetition in the Review that there is no evidence or very weak evidence might mean, as Andrew Doyle says, that this should lead to a stop on so called ‘gender affirming care’ including cross sex hormones.

The use of some of the language is unfortunate ( to put it mildly). ‘Transitioning’ is meaningless when the biological fact is that you cannot change your sex. ‘Gender dysphoria’ probably doesn’t exist or, at most, is a symptom ( see EDI Jester’s piece on the Diagnostic and Statistical Manual - the DSM - which I am including in Part 2). LGBTQ+ is a meaningless acronym. Talking of a ‘toxic debate’ is not helpful - we debate and the gender ideologues and anti-women activists are toxic (and don’t debate).

I actually think there is loads of evidence showing that gender affirming care is positively harmful. Take, as just one example, the two reports I just mentioned the other day ( especially the very extensive and authoritative Dutch report):

https://dustymasterson.substack.com/p/of-all-the-gin-joints

The Review shows that there is no evidence about the claims of risk of suicide if children are not affirmed. By the way, there was already plenty of research to show that this was untrue.

I don’t like the sound of research - why do we need research and doesn’t this sound like experimenting on children and young people!?

It is absolutely outrageous that the NHS adult gender services refused to co-operate with Dr Cass!! What are the Government doing about this!

Effectively, the Review refers to ‘transing away the gay’ referring to the fact that the vast majority of children at GIDS were either gay, lesbian or bisexual.

I agree with Andrew Doyle that we need inquiries into what went wrong at the BBC and how the NHS allowed this to happen. As you will see below, for the first time ever, the BBC have interviewed Helen Joyce!!

Given Cass’s comments on transitioning, we now need either much firmer guidance or, preferably, legislation to stop social transitioning in schools. Unfortunately, no account is taken of all the other children who are being forced to accept a lie when a child ‘transitions’!

Just a few thoughts from me. Please do let me have your comments. Now on with the articles etc

The Cass Review: a damning indictment of the NHS

It’s time to put a stop to “gender-affirming” paediatric healthcare.

ANDREW DOYLE

APR 10, 2024

The review into paediatric gender treatment by Dr Hilary Cass has finally been published. Its conclusions should herald the end of “gender-affirming” care in the United Kingdom, and its impact is likely to reverberate around the world. 

The review has shown that 89% of girls and 81% of boys referred to GIDS (Gender Identity Development Service) were either homosexual or bisexual. The NHS has been practising gay conversion therapy in plain sight, and this has happened because politicians have been too ignorant or too afraid to do anything about it.

Cass has explicitly noted how fear of standing up to ideologues has resulted in a situation in which “attempts to improve the evidence base have been thwarted by a lack of cooperation from the adult gender services”. We have long suspected that the “gender-affirming” model of healthcare has persisted because its critics were too intimidated to speak out. This has been confirmed by Cass’s final report.

The report finds that vulnerable young people who should have been supported with therapeutic treatment were fast-tracked onto lifelong medicalisation. The risks of puberty blockers are now clear, and Cass notes that there is no evidence to justify them. Most crucially, we now know that the common assertion that puberty blockers and cross-sex hormones reduce the risk of suicide is completely false.

Cass refers to the influence on the NHS of the World Professional Association of Transgender Healthcare (WPATH), and how its guidelines have been found “to lack developmental rigour”. The recent revelations of the “WPATH files”, internal messages and videos from the organisation, have shown that leading practitioners were aware that children could not give “informed consent” to the treatments they were prescribing. In addition, they were also aware that gay or bisexual youth and those with mental health and autistic conditions were disproportionately affected. More details about the WPATH files can be read here.

Given the significance of WPATH’s influence, now confirmed by the Cass Review, it is remarkable that the BBC has yet to report on the WPATH files. Like the NHS, the BBC has been promoting gender identity ideology as though it were uncontested fact. In the light of the Cass Review, surely an investigation into the ideological capture of the BBC should be initiated. 

School policy is beyond the remit of the report, but Cass notes that “social transitioning” – that is, adopting preferred names and pronouns – can increase the chances of a child proceeding on a “medical pathway”. It would be prudent for the Department for Education to bear this in mind when drafting future guidelines. 

Cass offers an important recommendation for patients aged between 17 and 25. At present. young people who turn 17 are treated as adults and can be prescribed cross-sex hormones without parental consent. Given that the human brain is not fully developed until the age of 25, the risks here are obvious. Cass had recommended that “NHS England should establish follow-through services for 17-25-year-olds at each of the Regional Centres, either by extending the range of the regional children and young people’s service or through linked services, to ensure continuity of care and support at a potentially vulnerable stage in their journey.”

In light of the Cass Review, we now need an urgent investigation into how ideological zealots were able to dominate the NHS and branches of government to the detriment of children. Those charities who once supported gay rights – most notably Stonewall – have been complicit in this scandal which has mostly harmed gay youth. Any government departments and quangos still associated with Stonewall should sever all ties immediately.

Both the Conservatives and the Labour Party ought to ditch their commitment to a ban on “trans conversion therapy” and recognise that this will effectively stymie the therapeutic efforts of medical practitioners to support gender nonconforming children. The proposed ban on “trans conversion therapy” is tantamount to a new form of gay conversion therapy. You can read my thoughts on this subject here.

Above all, there now needs to be a concerted cross-party effort in parliament to identify those responsible for harming so many children and to hold them accountable for their negligence. The NHS should never have been in the business of practising pseudoscientific methods at the behest of activists, and we must ensure that this never happens again.

Rachel Roberts in Epoch Times ( NHS Review: UK Children With Mental Health Problems May Have Been Rushed to ‘Transition’ 09 April) reports:

A landmark review into NHS care for children who say they are suffering from gender confusion has been published, criticising the way children have been put on inappropriate paths to drugs and surgery, and aiming to set out a more “holistic” method of treatment.

Dr. Hilary Cass made 32 recommendations in total, finding that evidence for so-called “gender care”—which includes health care professionals simply affirming a child’s chosen gender and allowing young children to take puberty blockers—is “remarkably weak.”

The review was commissioned by NHS England and NHS Improvement in 2020 following a huge rise in the number of children and young people seeking help for issues with their gender in the past few years. In 2021–22, the NHS reported more than 5,000 referrals to the Tavistock gender identity clinic, up from just under 250 who were questioning their gender a decade earlier.

The final report on Dr. Cass’s review of gender identity services for children and young people runs to almost 400 pages and has been close to four years in the making, following concern from many professionals and campaign groups of a “social contagion” among young people claiming to suffer dysphoria.

The report called for more research into the effects on young people treated for gender confusion, finding there is currently “no good evidence on the long-term outcomes of interventions to manage gender-related distress.”

The recommendations do not go far enough for many campaigners concerned about transgender ideology being pushed onto children because it does not call for the outright banning of social transitioning or teaching that there are different “gender identities” in schools.

Dr. Cass found that results of previous studies have been “exaggerated or misrepresented by people on all sides of the debate to support their viewpoint.”

Under new NHS guidelines, children under 16 are no longer allowed to be prescribed puberty blockers, except if they are enrolled in a medical trial. The report stressed that consent must be routinely sought for enrolment in studies that follow young people into adulthood.

Such a puberty blocker trial is expected to be up and running by December—but Dr. Cass said that alongside this, there should be more research done into psychotherapy.

The review warned that giving masculinising and feminising hormones to 16-year-olds should be done with “extreme caution,” and called for further research into the effects of prescribing these drugs to young people.

Dusty - this is a great shame that we only have ‘extreme caution’ - surely it should be halted without any evidence!!

Care Should Be ‘Holistic’ and ‘Personal’

Health care professionals have been reluctant to openly discuss their views in a conversation which has seen people bullied and vilified on social media, the report found.

Dr. Cass’s investigation heard from some parents who said they felt “forced” to affirm their child’s gender identity as they were scared of being labelled as “transphobic,” although other parents said transitioning had boosted their child’s social life and made them more popular.

The care of children and young people questioning their gender identity “needs to be holistic and personal,” the report said, following concerns that many children on the autistic spectrum or with mental health problems besides gender dysphoria are being allowed to “transition.”

The report calls for “an individualised care plan” for patients which should include screening for neurodivergent conditions, including autism, as well as a proper mental health assessment. It found that children who suffered abuse or serious problems at home were more likely to believe they were “transgender.”

Following the scandal over the treatment of young children at the Tavistock clinic in north London and its closure in March, all facilities offering gender care “must operate to the same standards as other services seeing children and young people with complex presentations and/or additional risk factors.”

In the wake of revelations that children as young as three were referred to the Tavistock clinic, the review said the approach to caring for younger children should be different from that offered to teenagers.

But there should be no lower age limit to accessing support and parents and families should be helped to ensure options “remain open and flexible for the child,” Dr. Cass recommended.

For pre-pubescent children, there should be a “separate pathway” of care within each regional network of services, and young children and their parents should be prioritised for “early discussion with a professional with relevant experience.”

Young people should not just be transferred to adult services once they turn 18, but instead there should be a “follow-through services” for 17 to 25-year-olds, with regional centres either extending the age range of their patients or through “linked services, to ensure continuity of care and support at a potentially vulnerable stage in their journey.”

Because young people are being made sterile through taking cross-sex hormones, the review recommends that all children should be offered “fertility counselling and preservation” before going down the route of medical intervention.

‘Referrals Should Come From a Medical Professional’

The report found that referrals to the now-closed Gender Identity Development Service (GIDS) at the Tavistock clinic were “unusual” in that they were accepted directly from GPs and from non-health care professionals including youth workers and teachers.

Dr. Cass said this practice should end and she supports proposals from NHS England for all referrals to come from medical professionals.

Following concerns from many politicians, teachers, and campaigners about the damage being done in allowing children to “socially transition,” Dr. Cass found that those who were allowed to change their names and pronouns at an earlier age or before being seen in clinic “were more likely to proceed to a medical pathway.”

But she found “no clear evidence” that allowing such a transition has any positive or negative mental health outcomes and “relatively weak” evidence for the effects in adolescence.

Partial transition “may be a way of ensuring flexibility,” the review said, adding that appropriately trained clinical staff should advise on the risks and benefits of social transition “referencing best available evidence.”

The report warns parents should be careful not to unconsciously influence the child’s “gender expression.”

Dr. Cass found there is a shortage of staff with the required skills to meet the needs of gender-confused young people. She said professionals have been reluctant to engage in the clinical care of gender-questioning children and young people due to weak evidence in the area, a lack of consistent professional guidance and support, and long-term implications of making the wrong judgment about treatment options.

She said there is a need for staff with the correct mix of skills to treat those who will go on a medical pathway, and those who can be helped by psycho-social therapy, and this should include a wide range of specialists such as paediatricians, psychiatrists, clinical nurse specialists, social workers, specialists in neurodiversity, speech and language therapists and occupational health specialists.

Endocrinologists and fertility specialists should also feature “for the subgroup for whom medical treatment may be considered appropriate.”

The review said NHS England must identify gaps in professional training programmes and develop training materials “to supplement professional competencies, appropriate to their clinical field and level.”

Separate Service for ‘Detransitioners’

NHS England should consider whether a separately commissioned service is needed for people who wish to “detransition”—meaning they wish to go back to presenting as their own sex and stop taking cross-sex hormones—given that people who regret going through this process might be hesitant to return to the same service they had previously used.

Given that some people may have had surgery that cannot be undone, the review says that “better services and pathways” are needed for a group of whom many are “living with the irreversible effects of transition and no clear way to access services.”

The percentage of people treated with hormones who then detransition is currently unknown because of the lack of long-term follow-up studies, but the report said it is believed that numbers are increasing and those coming off hormones must be carefully monitored.

Dusty - there is definitely a great need for better services for ‘detransitioners’.

The Private Sector

The report addresses concerns that some children will still be able to gain access to puberty blockers through private providers, many of whom have online clinics and are registered abroad.

As puberty blockers are no longer being prescribed to children on the NHS, the report recommends that no GP should be expected to “enter into a shared care arrangement with a private provider” if a young person has been given access to them via that route.

Dr. Cass said GPs had “expressed concern about being pressured to prescribe hormones after these have been initiated by private providers and that there is a lack of clarity around their responsibilities in relation to monitoring.”

The report added that the Department of Health and Social Care and NHS England must “consider the implications of private healthcare on any future requests to the NHS for treatment, monitoring and/or involvement in research,” noting that a young person’s eligibility to take part in the NHS study into puberty blockers could be affected if they took puberty blockers outside the study.

The GIDS at the Tavistock and Portman NHS Foundation Trust closed two weeks ago, with two new regional hubs launched in London and the north of England in a bid to move away from a single-service model.

Professor Steve Turner, president of the Royal College of Paediatrics and Child Health, said the review was a “massive undertaking” and the college will “closely consider the report’s recommendations.”

“For some time now, rising demand for gender identity services across the UK has led to significant waiting times for children with gender-related distress, leaving these young people particularly underserved and vulnerable,” he added.

“It’s obvious that more resources are needed to address the holistic health needs of this young cohort.

“As a college, we are clear that the needs of children and young people should be front and centre of how services are designed to care for them.”

Dr. Lade Smith, president of the Royal College of Psychiatrists, said, “Children who are gender questioning also commonly experience mental illness.

“It is extremely important that every child who is gender questioning has timely access to services that are holistic and respond to their individual needs.”

An NHS England spokesperson said the health service is “very grateful” for Dr. Cass’s work.

They added: “The NHS has made significant progress towards establishing a fundamentally different gender service for children and young people – in line with earlier advice by Dr. Cass and following extensive public consultation and engagement – by stopping the routine use of puberty-suppressing hormones and opening the first of up to eight new regional centres delivering a different model of care.

“We will set out a full implementation plan following careful consideration of this final report and its recommendations, and the NHS is also bringing forward its systemic review of adult gender services and has written to local NHS leaders to ask them to pause offering first appointments at adult gender clinics to young people below their 18th birthday.”

Dusty- note this last paragraph!

Aine Fox in The Evening Standard (!!!) ( Whistleblower: Refusal of adult gender clinics to take part in study ‘shocking’ 10 April) reports:

Dr David Bell © PA Media

A Tavistock trust whistleblower said he was “shocked” that adult gender clinics had refused to take part in research.

Dr David Bell, who wrote a report six years ago after colleagues raised concerns about the children’s gender service which closed last month, said he did not expect the “complete lack of co-operation of adult services” revealed as part of a major report published on Wednesday.

Dr Hilary Cass had, through her Independent Review of Gender Identity Services for Children and Young People, commissioned research tracking the journeys of young people who were seen by the now-shut Gender Identity Development Service (Gids) at the Tavistock and Portman NHS Foundation Trust.

The research could have encompassed outcomes for approximately 9,000 young people who moved from Gids into NHS adult gender dysphoria clinics.

Dr Cass described it as a “world leading opportunity” to add to the evidence base – something her report makes clear is sorely lacking in the area of gender care.

But six of the seven adult clinics declined to support the study, with reasons for not doing so including ethical considerations and concerns about funder motivation and political interference, with fears the resulting “high-profile national report” could be misinterpreted or misrepresented.

In a letter to John Stewart, national director for specialised commissioning in NHS England and NHS Improvement, dated last month, Dr Cass said that despite his “welcomed efforts to obtain cooperation, most of the NHS gender clinics have refused to take part in this research”.

Dr Cass said it had “not been at all straightforward trying to get this research off the ground” and had “absorbed a considerable amount of time and attention” from the review and delayed its work.

She said the study “follows usual NHS research practice” and was “only novel because of the sensitivity of the subject matter”.

Dr Cass said it was “hugely disappointing that the NHS gender services have decided not to participate with this research”.

She added: “I am frustrated on behalf of the young people and their families that the opportunity to reduce some of the uncertainties around care options has not been taken.”

Asked about it as her report was published on Wednesday, she told of her surprise that the adult services “weren’t keen to collaborate because I would have expected them to have a professional curiosity about what was happening in terms of long-term outcomes” for young people.

She added: “Certainly if they were confident that their model of care was the right one, they should have been really keen to see that research as much as we were so yes, it is disappointing.”

Dr Bell told the PA news agency: “I was shocked by the finding that the adult service had been asked and refused to co-operate. I didn’t think they would go that far.

“They seem to be wanting to, instead of being transparent, keeping the curtains shut so that we can’t be allowed to see what happens.

“And that is extremely worrying.”

NHS England has written to local NHS leaders informing them that a planned review of adult services will now become a “broader, systemic review of the operation and delivery” of gender dysphoria clinics (GDCs).

The letter “also makes clear that NHS England expects full cooperation from the GDCs in the delivery of the data linkage study”, meaning they will be required to participate in research.

Dr Bell, a retired consultant psychiatrist, welcomed the overall report as an “extremely balanced and calm” one, saying he feels vindicated for first reporting concerns raised to him at Gids.

He said: “It shows that all of us who raised these concerns all these years ago, although it’s taken a while, every single concern that we raised has been borne out by this study.”

He said it had taken “a while for people to listen to us”, and praised the tone of Dr Cass’s report.

“She has to absolutely frame it in such a way that most reasonable people will be able to take it in as a balanced and rational document,” he said.

“It’s not set out as an expose, that’s not its job. But behind the scenes there is a terrible expose.”

Dusty - hats off to Dr Bell!

Sex Matters have done an analysis

The Cass Review – initial analysis Wednesday 10th April

The Cass Review of gender-identity services for children and young people has published its final report and recommendations. Sex Matters says: This is a breakthrough. It’s a huge step forward, with multiple implications that will be hugely consequential.

Highlights Dr Hilary Cass succinctly explains how the medicalised treatment of youth with gender distress went so badly off course worldwide. She traces how a false global consensus was manufactured, according to which puberty blockers were safe and effective. This false consensus also regarded children as having stable gender identities and being best off on medical treatment pathways if they expressed any sort of gender incongruence. “It often takes many years before strongly positive research findings are incorporated into practice…. Quite the reverse happened in the field of gender care for children. Based on a single Dutch study, which suggested that puberty blockers may improve psychological wellbeing for a narrowly defined group of children with gender incongruence, the practice spread at pace to other countries. This was closely followed by a greater readiness to start masculinising/feminising hormones in mid-teens, and the extension of this approach to a wider group of adolescents who would not have met the inclusion criteria for the original Dutch study.” (p 13)

In the UK, the whistleblowers have been vindicated. Gender distress has been treated within the NHS in a way that is different from other sorts of distress, to the detriment of vulnerable children and adults. “Some practitioners abandoned normal clinical approaches to holistic assessment, which has meant that this group of young people have been exceptionalised compared to other young people with similarly complex presentations. They deserve very much better.” (p 13)

“We have to start from the understanding that this group of children and young people are just that; children and young people first and foremost, not individuals solely defined by their gender incongruence or gender-related distress.” (p 15)

Identity formation is, the report says, fluid and multifactorial. Clinicians told Dr Cass they can’t tell who would benefit from a medical pathway and who would not – and they know that the majority grow out of gender distress if not medicalised. That means children have been given treatments that there’s no evidence to support – that are in fact harmful – and in particular, the NHS has done this. Dr Cass dismisses any notion that puberty blockers or indeed hormones have any part in standard treatment for under-18s. The report explicitly says that the medical pathway will not be right for most young people with gender issues. “Young people’s sense of identity is not always fixed and may evolve over time.” (p 21)

“Clinicians have told us they are unable to determine with any certainty which children and young people will go on to have an enduring trans identity.” (p 22) “The focus on the use of puberty blockers for managing gender-related distress has overshadowed the possibility that other evidence-based treatments may be more effective.” (p 31) There’s a reminder that the WPATH evidence and the standards of care are of the lowest medical quality, with the pyramid showing standards of medical evidence on p 55.

In the summary, the report says: “The World Professional Association of Transgender Healthcare (WPATH) has been highly influential in directing international practice, although its guidelines were found by the University of York appraisal process to lack developmental rigour.” (p 28) “The findings raise questions about the quality of currently available guidelines. Most guidelines have not followed the international standards for guideline development, and because of this the research team could only recommend two guidelines for practice – the Finnish guideline published in 2020 and the Swedish guideline published in 2022.” (p 27)

There’s a strong challenge to the Memorandum of Understanding that currently commits British practitioners of counselling and psychotherapy to an affirmative approach. “Professional bodies must come together to provide leadership and guidance on the clinical management of this population. taking account of the findings of this report.” (Recommendation 31). Dr Cass decisively refutes the idea that suicide prevention is a reason for medicalising gender distress in youth, saying: “It has been suggested that hormone treatment reduces the elevated risk of death by suicide in this population, but the evidence found did not support this conclusion.” (p 33)

She proposes steps to reduce access to private prescriptions for puberty blockers or hormones. She:

● recommends that GPs and other clinicians do not get involved in shared care with private providers

● reminds pharmacists that they are responsible for the suitability and safety of what they’re dispensing, reminding them that they could be criminally liable

● suggests that the Department of Health should outlaw the provision of puberty blockers from clinicians from pharmacies that are not licensed or from doctors that are not licensed in the UK.

She warns families that if they get puberty blockers privately they will not be eligible for an NHS puberty blockers trial.

The description of GIDS is absolutely damning in several ways:

1. The clinic deviated from its agreed service specification, which limited it to medicalising only the tiny cohort who matched the early Dutch studies.

2. The record-keeping was so bad that there should probably be referrals to the General Medical Council (p 136–137).

3. Both GIDS and the adult gender clinics flatly refused to cooperate with Cass on a long-term follow-up study. They “thwarted” her attempts. That’s a disgrace because there’s no high-quality data on long-term outcomes worldwide and her review was attempting to provide it. (Appendix 12 is a letter to the head of specialist NHS commissioning, explaining why she hasn’t been able to publish the expected findings of the investigation into longer-term outcomes for the puberty-blocked children.)

4. GIDS’s handling of its long-promised puberty-blockers trial fell far below acceptable standards: “The adoption of a treatment with uncertain benefits without further scrutiny is a significant departure from established practice. This, in combination with the long delay in publication of the results of the study, has had significant consequences in terms of patient expectations of intended benefits and demand for treatment.” (p 25). There is extensive analysis of the changing patient profiles and some exploration of the possible causes for this. The report concludes that cross-sex hormones will rarely be right for anyone under 18.

Strikingly, Dr Cass goes outside her remit to suggest that there should be specialised follow-on services for 18 to 25 year olds, for two reasons: currently, the transfer from child to adult services is a point of vulnerability, and brains are not fully developed until 25. Dr Cass talks about detransitioners sympathetically and seriously, suggesting that they need specialised care and possibly not in the same places as the gender clinics. This is the first acknowledgement of detransitioners and their needs in the NHS.

This report totally undermines any case for a legislative ban on “conversion practices for gender identity”. [Dusty - this is a vital point]. It says: “The intent of psychological intervention is not to change the person’s perception of who they are but to work with them to explore their concerns and experiences and help alleviate their distress, regardless of whether they pursue a medical pathway or not. It is harmful to equate this approach to conversion therapy as it may prevent young people from getting the emotional support they deserve.” (p 150)

Schools were outside Dr Cass’s remit, but she says: “The importance of what happens in school cannot be under-estimated; this applies to all aspects of children’s health and wellbeing. Schools have been grappling with how they should respond when a pupil says that they want to socially transition in the school setting. For this reason, it is important that school guidance is able to utilise some of the principles and evidence from the Review.” (p 158) All the justifications that might be used to argue for allowing a child to socially transition at school have more or less been taken off the table: “The systematic review showed no clear evidence that social transition in childhood has any positive or negative mental health outcomes, and relatively weak evidence for any effect in adolescence. However, those who had socially transitioned at an earlier age and/or prior to being seen in clinic were more likely to proceed to a medical pathway.” (p 31)

The review suggests that allowing non-conforming gender expression does not mean hiding a child’s sex. This may be what is meant when the report refers to partial social transition: “The approach taken to social transition is very individual but it is broadly understood to refer to social changes to live as a different gender such as altering hair or clothing, name change and/or use of different pronouns. There is a spectrum from relatively limited gender non-conforming changes in appearance in adolescence to young people who may have fully socially transitioned from an early age and be ‘living in stealth’ (that is, school friends/staff may be unaware of their birth-registered sex).” (p 158)

There is a strong suggestion that there should be a review of what went wrong at GIDS: “There are clearly lessons to be learned by everyone in relation to how and why the care of these children and young people came to deviate from usual NHS practice, how clinical practice became disconnected from the clinical evidence base, and why warning signs that the service delivery model was struggling to meet demand were not acted on sooner.” (p 74)

Dr Cass talks about safeguarding and points out the reckless failure to consider the safety of these children at every level of the NHS, including changing their NHS numbers. There’s a recommendation that the Department of Health looks at this (Recommendation 28, p 44). Where the report could have been better - Language: it uses trans male, trans female, cisgender; it says “sex assigned at birth” many times. It occasionally says “gender” when what is meant is sex. On occasion there is false balance, for example claiming that the standard of the evidence on puberty blockers is misstated on both sides, when in fact one side has pushed for experimental, life-changing drugs to be widely available for children and the other was advocating caution in the absence of any evidence that these drugs would help resolve gender distress. Two references to the “toxicity” of the debate give the impression that there is equivalence between people calling for an evidence-based therapeutic approach and aggressive name-calling and closing-down of debate by defenders of the medical pathway. The report suggests that pre- and post-pubertal children may need different treatment, implying that social transition may be acceptable for some: “There should be a distinction for the approach taken to pre- and post-pubertal children when considering the most appropriate interventions. This is of particular importance in relation to social transition, which may not be thought of as an intervention or treatment because it is something that generally happens at home, online or in school and not within health services. (p 30) The report leaves open the possibility that some people have an innate gender identity that in some unspecified way differs from their sex, and consequently the idea that medical intervention may be right for them. There is a reference to whether people see themselves as “male, female or something else”; the report says non-binary is a growing cohort which needs consideration. (There is nothing about what their healthcare needs might be.) There is mention of online and peer influences as drivers of transgender identities or gender confusion but no mention of schools as a driver, i.e. that schools are teaching the contested idea of gender identity. More generally, there’s a blind spot about the role of schools, both as causes and as recipients of social transition, and at times a worrying conflation of gender, gender nonconformity and having a special gender identity. On the idea of “partial social transition”, which Dr Cass briefly raises, there is no mention of the impact on other people, particularly other children in school. Social transition is not defined. The report acknowledges that an early social transition makes puberty more difficult and is predictive of a medical transition. The report suggests partial social transition may be preferable, but does not say what this is.

The strong statements in the interim review about needing holistic care for these children remain, but one wonders why, if that’s the case, there are specialist gender centres at all, as opposed to more CAMHS resources. [Dusty - I think this is a very important point]. One reason may be that, as the report says, people who are on waiting lists for a long time may go off and find their own solutions, which tend to be narrow and singular (i.e. blockers/hormones). There is positive endorsement of a clinical trial of puberty blockers, and of high-quality trials of other treatment protocols. This is somewhat at odds with the clear recognition that most desist and that it is simply impossible to tell which children will persist or desist.

Conclusion

This is a major step forward, dispelling myths on several fronts, and setting out ways to offer better, safer care for children and young people with referrals for gender-related issues. The report is clear that there is much more to do but it provides a strong foundation and emphasises the importance of building a better evidence base. While schools were outside its remit, there are helpful pointers there too.

LGB Alliance response to the final report from the Cass Review

10 April 2024

LGB Alliance welcomes the final report of the Cass Review, published today, and hopes that it will usher in the end of a global medical scandal that continues to undermine the health and welfare of so many young people. However, we warn that its many excellent recommendations can only be implemented if the ideological “capture” of clinical bodies is tackled and reversed. This concern is borne out by Dr Cass’s remark that “attempts to improve the evidence base have been thwarted by a lack of cooperation from the adult gender services” (p. 20). Why did these services thwart the work of an independent review? How can this shocking defiance be addressed and remedied?

Dr Cass’s report has clearly been prepared with painstaking care. We acknowledge her use of language we reject (e.g. cisgender, “assigned at birth”), in a clear effort not to alienate those who take a different view. It is part of her general approach, which displays great compassion for young people presenting with “gender dysphoria”.

As Cass notes, most of the teenagers involved are lesbian, bisexual or gay: she quotes figures from the GIDS service in 2016 (Holt et al., 2016; the most recent data available) which reported sexual orientation in 57% (97) of a clinic sample of patients over 12 years of age for whom this information was available. 68% of girls were only attracted to other girls and 21% to both girls and boys. In the case of boys, 42% were attracted to other boys and 39% to both girls and boys. (p. 18). In other words, 89% of girls and 81% of boys were either homosexual or bisexual. These are extraordinary figures. But gay teens aren’t sick. If they mistake their emerging sexual orientation for a “gender identity” issue, they need assurance that it is fine to be gay, lesbian or bisexual, not affirmation that they are the opposite sex and that drugs and surgery will relieve their distress.

Even though LGB teens are at the centre of this issue, the University of York’s international survey found that only two out of the ten clinics surveyed broached the subject of sexuality/sexual orientation with its patients presenting with gender distress (p. 135). The York synthesis of international guidelines found that the guidelines issued by the World Professional Association of Transgender Health (WPATH), a pro-affirmation lobby group that has had immense – and we would say, malign – influence on practice in this field in the UK and elsewhere, does not include sexual orientation as a “domain” that should be assessed (p. 135, Table 7).

The often-cited clinical consensus on the benefits of the “gender-affirming” approach is misleading. It is based on a circular process in which WPATH quotes the guidelines of other organisations – which were either prepared with WPATH’s help or based on WPATH’s own guidelines.

It is not commonly known that most of those seeking “gender care” are LGB teenagers, and in particular lesbians. The public perception is doubtless influenced by the fact that LGBTQ+ support groups mainly endorse “gender affirming care” (Appendix 9, p. 7), in which a girl who says she is a boy must be affirmed in that belief. LGB Alliance emphatically rejects that view.

Cass rightly observes that in some strictly religious cultures, being transgender is seen as preferable to being same-sex attracted as it is then perceived as a physical rather than a psychological issue (p. 119).

Most children who are unhappy with their sexed bodies later desist. “A study followed 2,772 adolescents from age 11 to 26. Gender non-contentedness (as defined by the question “I wish to be of the opposite sex”) was high in early adolescence, reduced into early 20s, and was associated with a poorer self-concept and mental health throughout development. It was also more often associated with same-sex attraction when compared to those who did not have gender non-contentedness” (p. 122, from Rawee et al. 2024). They do need time to think, but as Cass points out, “There is no evidence that puberty blockers buy time to think” (p. 32).

A survey of detransitioners found that 23% gave homophobia or difficulty accepting themselves as lesbian, gay or bisexual as a reason for transition and subsequent detransition (p. 188). LGB Alliance is pleased that these figures will now finally reach a wider public, but full of sadness and frustration that it has taken so long.

It is extremely worrying that precisely the response recommended by Cass – a holistic approach, involving careful exploration of the underlying issues, is rejected by the secretive but influential Coalition Against Conversion Therapy, chaired by Igi Moon – and by all its many signatories. They regard an exploratory approach as a “conversion practice” and that is what they seek to outlaw with their drive to ban “transgender conversion practices”. LGB Alliance was very pleased to see the recent announcement by the professional organisation UK Council for Psychotherapy (UKCP) that it has withdrawn its signature from the Memorandum of Understanding on Conversion Therapy – and cancelled its membership of the Coalition Against Conversion Therapy – because it rejects the inclusion of minors in the MoU. Hopefully more will soon follow. Cass recommends that clinicians should “seek to understand the child/young person’s emerging sexuality and sexual orientation, consistent with assessments in other adolescent settings, where deemed appropriate to age and context.” (p. 143).

Cass refers to a very worrying situation – in part the result of the efforts by Igi Moon’s group and other “affirmative approach” activist clinicians. That is the reluctance of clinicians to engage in the clinical care of gender-questioning children and young people. They are worried about making the wrong judgment and also express concerns about potential accusations of conversion practice when following an approach that would be considered normal clinical practice … when working with other groups of children and young people.

The Report makes 32 important recommendations, which LGB Alliance is pleased to endorse. We single out just a few that address key concerns:

Key recommendations:

On young children:
“When families/carers are making decisions about social transition of pre-pubertal children, services should ensure that they can be seen as early as possible by a clinical professional with relevant experience.”

Our comments
Some tomboys and “feminine” boys are hearing at school that they might be the opposite sex. If they succumb to this false propaganda, they should be referred to a mental health professional. Teachers are NOT qualified to make any decisions in this area: more needs to be done to halt “social transition” at school.

On children and young people in general:
“Clinicians should apply the assessment framework developed by the Review’s Clinical Expert Group, to ensure children/ young people referred to NHS gender services receive a holistic assessment of their needs to inform an individualised care plan. This should include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment.”

Our comments
The key word here is “holistic”. All too often, distress about emerging sexual orientation and diverse other factors are ignored, and the focus is entirely on “gender”.

On the age group 17 to 25:
“NHS England should establish follow-through services for 17-25-year-olds at each of the Regional Centres, either by extending the range of the regional children and young people’s service or through linked services, to ensure continuity of care and support at a potentially vulnerable stage in their journey. This will also allow clinical, and research follow up data to be collected.”

Our comments
This is a very welcome addition. At present, 17-year-olds are referred to adult services. There is a clear need for a bridging service, acknowledging that the prefrontal cortex, which governs decision-making, does not mature until around age 25.

On detransitioners:
“NHS England should ensure there is provision for people considering detransition, recognising that they may not wish to reengage with the services whose care they were previously under.”

Our comments
LGB Alliance has called several times for a dedicated service to cater for the complex needs of detransitioners, many of whom are LGB. They are dealing with a range of mental and physical issues – often including shame. Most have no wish to return to those who gave them such poor care, and they are left completely in the lurch.

On research:
“The evidence base underpinning medical and non-medical interventions in this clinical area must be improved. Following our earlier recommendation to establish a puberty blocker trial, which has been taken forward by NHS England, we further recommend a full programme of research be established.”

Our comments
Although this is obvious, those who promote the “gender-affirming” approach consistently resist calls for research in this area. After all, children “know who they are”.

Dusty - as I mention above, I do not agree that there should be research.

On private operators:
“The Department of Health and Social Care should work with the General Pharmaceutical Council to define the dispensing responsibilities of pharmacists of private prescriptions and consider other statutory solutions that would prevent inappropriate overseas prescribing.”

Our comments
This is crucial. Whether driven by a desire for profit, ideological zeal, or both, private operators are springing up to fill the gap left by the NHS’s new more cautious path. Some have no safeguards whatsoever and are plying an unregulated drug market. The recent approval by the Care Quality Commission of the new Gender Plus Hormone Clinic is of particular concern.

The Report carefully skirts around an important problem in dealing with gender dysphoria: “Because gender incongruence is not considered to be a mental health condition clinicians are often reluctant to explore or address co-occurring mental health issues in children and young people presenting with gender distress” (p. 18). This refers to the reclassification of gender dysphoria/incongruence in the DSM-V and ICD, which no longer regard it as a mental disorder. Nonetheless, the Report recommends: “Identifying and treating mental health difficulties should be an integrated part of the care for children and young people presenting with gender dysphoria.” (p. 142).

For LGB Alliance, the final report of the independent Cass Review highlights the medical scandal that is underway, the main victims of which are lesbian, gay and bisexual teens. It provides stark if overdue proof of the need to separate TQ+ activism from LGB groups. Why? Because all TQ+ groups campaign vigorously for the “gender affirming” approach to minors with gender dysphoria – from social “transition” to puberty blockers, cross-sex hormones and mastectomies. The findings of the Cass Review make it indisputably clear that such support is not just misguided but harmful – especially to LGB teens.

In her Foreword to the report, Dr Cass says: “There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.” Let us all redouble our efforts to discuss this serious healthcare issue in the measured language it deserves. Let us proceed on the assumption that we all want distressed children and young people to receive the best possible care. No one who hurls abuse at people with different views can contribute to this shared goal.

Dusty - exactly, see the anti-women activists at LWS in Edinburgh.

Cass Review final report – our statement

• Transgender Trend

  April 9, 2024

The Cass Review final report has been published. We thank Dr Cass and her team for all their methodical and careful work to produce an extraordinary document that will have influence worldwide.

In its breadth and scope, Dr Cass has produced a world-leading guideline on the care of children and adolescents experiencing gender-related distress.

We hope that this government and all political parties will actively support NHS England to follow and implement the report’s critical, evidence-based findings.

Dr Cass and her team have reviewed and analysed global research evidence and guidelines in transgender health care to establish an evidence base for treatments within the NHS, along with research protocols to address the many gaps in the evidence.

Crucially she has considered children and adolescents holistically through a framework of childhood development and adolescent mental health, and within a cultural and social environment unique to this generation.

Not only that, Dr Cass has produced a detailed and comprehensive service model and practical recommendations for a treatment pathway that will bring the NHSE service into line with normal standards of paediatric healthcare.

The information and recommendations in the report de-mystify the condition of gender dysphoria as something that is uniquely specialised, and places it within the appropriate framework of child and adolescent mental health services. As part of a psychosocial treatment pathway it incorporates standard mental health treatments which have been shown to be effective in the treatment of adolescents with a range of difficulties and adverse life experiences.

We are pleased to see that the final report has addressed some of our biggest concerns:

• The establishment of a follow-through service for 17–25-year-olds, in line with other mental health services. This is critical to ensure this age group receives the same standard of care as younger adolescents.

• Acknowledgment of the lack of evidence for the benefits of cross-sex hormones, the need for caution and the importance of data collection and follow-up. NHS England must now follow the recommendation for a review of cross-sex hormones and include them in a broader research programme. We would like to see NHSE ending the routine prescription of cross-sex hormones, in line with the puberty blockers policy.

• The recommendation for provision of specialised NHS services for detransitioners and those who regret their medical transition. This is an urgent requirement.

• Insufficient research on social transition, inconclusive evidence of any benefits but clear risk of creating persistence of an identity that would in all likelihood have resolved by itself. We hope that the government will use this information to end the practice of social transition in schools carried out by untrained adults. The impact on other children of adults pretending a child has changed their sex is outside the terms of reference for this report, but it is something the government must address.

• The need for support for siblings of children who identify as the opposite sex. This must be a priority. We would like this extended to the children of adult transitioners.

• No formal science-based training in psychotherapy, psychology or psychiatry teaches or advocates ‘conversion therapy.’ Normal “exploration of complex psychosocial challenges and/or mental health problems an adolescent may be experiencing is essential to provide diagnosis, clinical support and appropriate intervention”, and it is harmful to equate this approach to ‘conversion therapy.’

• Evidence of the disproportionate number of same-sex attracted and bisexual young people referred to the Tavistock GIDS.

• The inclusion of autism assessment and acknowledgment that this often goes undiagnosed in girls.

• An acknowledgment of social influences, including pornography, online and social media and peer pressure. The report points out that ‘social contagion’ is the most hotly contested explanation for the exponential rise in the number of children adopting a trans identity, but the examples included show the influences clearly.

• Although no direct reference to Rapid Onset Gender Dysphoria, acknowledgment throughout the report that the majority of referrals are teenage girls who developed gender dysphoria at or after puberty and that this is a completely new cohort.

Throughout the report Dr Cass documents a lack of cooperation and in some cases obstruction from GIDS and some of the adult gender clinics. This meant that not all of the specially commissioned research into outcomes for gender healthcare could be completed. Although the NHS has promised to continue the research, this attitude shows the depth of opposition in some parts of the NHS to the Cass Review reforms.

In the Key points and recommendations the report points out just how much of an outlier the medical pathway established at the Tavistock GIDS actually was:

‘23. The adoption of a treatment with uncertain benefits without further scrutiny is a significant departure from established practice. This, in combination with the long delay in publication of the results of the study, has had significant consequences in terms of patient expectations of intended benefits and demand for treatment.’

That this was allowed to happen, with so many children’s health put at risk, with irreversible and unknown outcomes, is a national scandal. What this report exposes is that obstruction to mending the service is ongoing. A crucial part of the development of an evidence-based service is gathering the data, but some efforts by the Review to collate the evidence of long-term outcomes have already been thwarted:

‘91. A strand of research commissioned by the Review was a quantitative data linkage study. The aim of this study was to fill some of the gaps in follow-up data for the approximately 9,000 young people who have been through GIDS. This would help to develop a stronger evidence base about the types of support and interventions received and longer-term outcomes. This required cooperation of GIDS and the NHS adult gender services.

92. In January 2024, the Review received a letter from NHS England stating that, despite efforts to encourage the participation of the NHS gender clinics, the necessary cooperation had not been forthcoming.’

The report states:

‘2.34 However, there are clearly lessons to be learned by everyone in relation to how and why the care of these children and young people came to deviate from usual NHS practice, how clinical practice became disconnected from the clinical evidence base, and why warning signs that the service delivery model was struggling to meet demand were not acted on sooner.’

We hope that this report will result in lessons learned more widely: that the medical scandal at the Tavistock GIDS did not happen in a vacuum. In terms of the care of children and young people of this generation, society more widely has some responsibility for the encouragement of children towards this medical pathway. Social transition in schools is one example:

‘12.12 The MPRG [ Major Projects Review Group] is concerned that some children living in stealth have a common, genuine fear of “being found out”, suffering rejection either due to not having taken friends into their confidence (withholding personal information regarding biological sex or specific sex-based experiences), or due to trans prejudice or transphobia. They observed that this fear of “being found out” is driving a sense of urgency to access puberty blockers, which may not allow consideration of other pros and cons of the treatment.’

We must also look at the role of the internet, early access to smartphones and the kind of information children are accessing with no proper guidance from adults:

‘8.47 It is the norm that all experiences of health and illness are understood through the norms and beliefs of an individual’s trusted social group. Thus, it is more likely that bodily discomfort, mental distress or perceived differences from peers may be interpreted through this cultural lens.

8.48 More specifically, gender-questioning young people and their parents have spoken to the Review about online information that describes normal adolescent discomfort as a possible sign of being trans and that particular influencers have had a substantial impact on their child’s beliefs and understanding of their gender.’

The report also references the failure in safeguarding within the clinical setting, which now must also be addressed in other settings. In schools, the same dynamic can be observed when as soon as the word ‘transgender’ is mentioned, all safeguarding responsibilities towards children seem to be forgotten:

‘10.43 As with all health care provision, when working with children and young people safeguarding must be a consideration. There are complex ways in which safeguarding issues may be present. Clinicians working with children and young people experiencing gender dysphoria have highlighted that safeguarding issues can be overshadowed or confused when there is focus on gender or in situations where there are high levels of gender-related distress.’

Children have been utterly failed and The Cass Review final report is not just a wake-up call for NHS England, but for the media, for politicians, for childcare professionals and for all adults who have cheerleaded this experiment on children with no questions asked: it has been the failure of society as a whole to safeguard the health and welfare of our children.  

Interview with Helen Joyce on Radio 5 Live ( wonders will never cease!)

https://twitter.com/SexMattersOrg/status/1777963127251800436

Endpiece

Whoa, that was a piece of work, Terven! Part 2 coming up soon!

If you like this update, please share with a friend. Until next time, Terven. This isn’t over yet! Please subscribe for free, like and comment.