Some thoughts on the Cass review

The interim Cass report is deeply worrying for trans children and parents who desire their good.

The Cass interim report does not say, any child being refused puberty blockers they desire “should have a formal diagnosis and formulation, which addresses the full range of factors affecting their physical, mental, developmental and psychosocial wellbeing”. That is, it does not sufficiently recognise that refusing treatment may also do harm to a child.

Puberty blockers (PB) or cross-sex hormones (CSH) are called a “life-changing intervention”, but the life-change can be for good, helping a child avoid the wrong puberty, and that is not sufficiently recognised by the Review yet.

Doctors and patients, here, may have different aims for treatment. Doctors may wish to alleviate immediate distress, and see inhibiting development of sexual characteristics as a bad thing. But children and parents want their distress alleviated too, and both reasons are good and sufficient to justify prescribing.

That said, there is a lot of good in the report. Local services should help with distress and other conditions such as “autism spectrum disorder” (sic), though CAMHS, child and adolescent mental health services, are underfunded. There should be more expertise, and shorter waiting lists. The report says “assessments should be respectful of the experience of the child”.

The report says there should be more systematic research on outcomes. There its problem is with medical ethics. A doctor should act for the good of their particular patient, and not others. This limits research, which is for the good of the whole community, not for the particular patient. The NHS asks for consent to research, but research is not its principle aim. The review’s recommendation of a “learning health system” where treatments are under academic review is a revolutionary change, which might benefit patients.

Paragraph 1.7 worries me. It says there is disagreement on whether children can be really trans, so that they need to transition, and whether questioning gender is just part of growing up. Possibly both can be true for different children. Read with 1.14, it shows a failure to see the value of affirmative care. No doubt some staff have said they feel “under pressure to adopt an unquestioning affirmative approach”, but the main pressure is the other way. The High Court used Keira Bell’s case, and a highly unorthodox approach to evidence in judicial review, to shut down the prescription of puberty blockers. The mainstream media is hostile to PBs. There are any number of practitioners groups which take an unquestioningly hostile view of trans treatment.

If there is “predominantly an affirmative, non-exploratory approach” to care, why do only a fraction of those children referred get prescribed PBs? The Court of Appeal in the Bell case heard evidence it was only 16% of patients discharged in 2019/20, of whom only half had started CSH.

But I like Dr Cass’s letter to the children saying they need more services. Some good could come of the report. If evidence is systematically collected it will include evidence of successful transitions and flourishing lives.

I read it because of the Observer editorial, which takes an absolutist anti-trans position: they think PBs for children are always wrong. The vast majority of those on PBs go onto CSH, says The Observer, against the evidence cited above. To them, even though people revert because of transphobia, even though reverters retransition, a single detransition is evidence that no trans child should receive treatment. To them, all the wrong is in giving PBs. They don’t believe children can be really trans. Cass at least admits the possibility.

Dr Cass tells the children that there will be opportunities to get involved with the review. Trans children and their parents should take all opportunities. The haters certainly will.