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Silver-level article

Cass Review

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The cover of the final published version of the Cass Review (2024), featuring an AI-generated image of a kid with wonky hands bolted to a wall.
It's a social construct
Gender
Icon gender.svg
Spectra and binaries

The Independent Review of Gender Identity Services for Children and Young People, more commonly known as the Cass Review or Cass Report, is a 388-page government report on the provision of gender-affirming care to young people in the United Kingdom.[1][2] Commissioned by the NHS as an "independent review" headed by paediatrician Hilary Cass, the report took four years to produce and led to swift, sweeping policy changes (including a ban on puberty blockers) after its release in April 2024.[3][4]:10 As it was a review (and the final report was not itself subject to traditional peer review[5] although that matters less than one may think), it didn't itself produce new evidence.[4]:6

Prior to Cass, one review in this area of medicine was Cornell University's 2018 review by the What We Know Project.[6] Out of nearly sixty studies considered by that review, the Cass Review and its associated systematic reviews for some reason found occasion to reference precisely zero of the same papers. The Cass Review has, predictably given some of its content and background, been well-received by anti-trans lobby groups and activists.[2] Outside the echo chamber inhabited by transphobes, it has been roundly criticised by major medical organisations for its limitations and serious methodological flaws,[7][3] and has been cited as an example of policy-based evidence making.[8][9][10] Despite its flaws, the Cass Review doesn't call for a ban on any of the options that doctors and their patients might pursue.[11]:4–7

Rigging the game[edit]

One senior psychiatrist at a gender identity clinic in England told a national newspaper in the UK that the failure to include those with personal or professional experience “had concerned many within the field.” They said: “The terms of reference stated that the Cass Review ‘deliberately does not contain subject matter experts or people with lived experience of gender services’ and Dr. Cass herself was explicitly selected as a senior clinician ‘with no prior involvement … in this area.’ Essentially, ignorance of gender dysphoria medicine was framed as a virtue. I can think of no comparable medical review of a process where those with experience or expertise of that process were summarily dismissed.” WPATH and USPATH agree completely.
World Professional Association for Transgender Health (WPATH)[12]

Hand-picked from a shortlist of one[edit]

The NHS announced in January 2020 that it was establishing an "independent expert group" chaired by Hilary Cass to "support a review of puberty suppressants and cross-sex hormones" in paediatric gender care.[13] In September 2020, the NHS announced that Cass would also head this review, which it billed as an "independent review into gender identity services for children and young people."[14] Both press releases hailed her as "Dr Hilary Cass OBE, former President of the Royal College of Paediatrics and Child Health."[13][14] They didn't mention that Cass lacks clinical experience or expertise in caring for trans youth.[15]

The World Professional Association for Transgender Health condemned Cass's appointment as occurring "without any transparent or competitive process" in a statement released after the review's publication in 2024.[15] A freedom-of-information (FOI) request that same year revealed that Cass was the only candidate considered for the job (from a "shortlist" of one).[16][17]

Tory minister Kemi Badenoch, a DeSantis[18] and Murdoch darling,[19] proudly admitted in a June 2024 tweet that political manipulation paved the way for Cass.[20] According to Badenoch, the review wouldn't have been commissioned under a Labour government, and it was "when the ministers changed" that her party no longer faced "opposition from the system."[20] She said a decisive factor in the production of the Cass Review was "having gender-critical men and women in the UK government, holding the positions that mattered most in Equalities and Health."[20] Cass was not-coincidentally awarded a life peerage in the House of Lords by transphobe and outgoing Prime Minister Rishi Sunak in July 2024.[21][22] The aforementioned Badenoch took credit, saying she "managed to get Dr Hilary Cass a peerage", and that if she were made Tory leader, would offer J. K. Rowling one, too.[23][24]

The Cass Review appears to have engaged in questionable handling of public records from an early stage.[25][26][27] Medium blogger "Reactive Ashley" filed an FOI request seeking "internal drafts" spanning October 2020 to April 2024.[26] The response: "NHS England did not receive snapshots or drafts," as this fell "outside of the review's data handling policy."[26] "Reactive Ashley" subsequently told the Information Commissioner's Office that "a large collection of public records may have been concealed or destroyed."[27]

Engagement with anti-LGBT perspectives[edit]

Hilary Cass discussing criticism of her report, April 2024.

The Review consulted many non-experts, and many sources who were explicitly, self-admittedly in denial that transgender minors, the topic of the review, exist at all (32 percent of those surveyed).[11]:10 Cass herself was presented as impartial and thus especially fit to carry out the review.[28] The interim report released by the NHS in February 2022 described her as having "no prior involvement or fixed views" amidst an alleged clinical "polarisation" on trans healthcare.[29] However, according to a white paper released in August 2024 by Max Davie and Lorna Hobbs, clinicians working in child and adolescent gender care in the UK, she was "known by colleagues to oppose medical transition" at the time of her appointment.[30][31][32]

Davie and Hobbs' paper included a footnote stating that Cass had "strongly recommended" the anti-trans book Irreversible Damage: The Transgender Craze Seducing Our Daughters.[30][31][32][33][34] Screenshots of this footnote were widely shared on social media.[33] Davie updated the paper to clarify that Cass called him to "discuss [his] potential involvement" in the review "towards the end of 2020."[30][34] In Davie's recollection, Cass "expressed concerns about GiDS practice" during this conversation, finding it "shocking" that "97% of children" prescribed puberty blockers progressed to HRT.[34][34] When Davie countered that this was likely due to "accurate triage," Cass reportedly "recommended that [he] read Irreversible Damage."[30][34] Davie claimed that he first became "aware of Dr Cass's scepticism about the GiDS model" when they collaborated on a NICE project.[30][34] Cass dismissed the Irreversible Damage anecdote as "baseless and wholly untrue" in response to a request for comment from PinkNews.[33] In the statement, she denied having ever read the book and asserted that "the suggestion that I recommended it to anyone is fabrication," noting that she had "already been reviewing the evidence for six months" at the time of its publication.[33] Davie later removed (but did not retract) the anecdote from the paper, stating that "Dr Cass obviously saw [it] as an attack" and that he and Hobbs had set out to "robustly critique the review, not make personal attacks."[35]

Cass' statement to PinkNews raised new questions. It suggests that Cass believes her work on the Cass Review began in January 2020. It also implies that she has been aware of Irreversible Damage since its American release. The book was initially released by Regnery Publishing in June 2020.[36] It was not published in the UK until December 2020.[37][note 1] Regnery is a right-wing imprint that mainly sacrifices trees for pundits like Ann Coulter and Dennis Prager.[31][38] Regnery also has a history of endorsing anti-science junk such as Peter Duesberg's Inventing the AIDS Virus (1996).[39] UK publisher Swift Press has cultivated a similar reputation for "standing up to groupthink."[40] The author of Irreversible Damage, Abigail Shrier, is a conservative opinion columnist.[41][42] Natalie Wynn characterised Shrier's book as "essentially to transmasculine people what The Transsexual Empire was to trans women."[43] The book centres on Lisa Littman's debunked hypothesis that peer pressure and social media are "seducing" AFAB teens into identifying as trans boys.[44][note 2]

Cass has followed Graham Linehan, LGB Alliance, and Transgender Trend online, among other anti-trans activists and organisations.[46][47][48] In 2022 she met with Patrick Hunter of the anti-trans SPLC-designated hate group[49] SEGM to discuss a stitched-up report used to ban gender-affirming care in Florida.[50][51] Hunter also belongs to the Catholic Medical Association,[50][51] an anti-abortion, anti-gay[52][53][54] organisation that opposes gender transition because, according to their interpretation, it "violates the teachings of the Church."[55]:33–34 Cass was due to speak at a cancelled 2022 teleconference for trainee child psychiatrists in the UK alongside Lisa Littman, Transgender Trend founder Stephanie Davies-Arai, Genspect[note 3] founder Stella O'Malley, and anti-trans columnist Helen Joyce.[57][58]

Exclusion of trans-friendly perspectives[edit]

With a transphobe specially recruited as its lead author, the Cass Review systematically excluded input from expert clinicians, trans people, and other stakeholders.[15][28][4]:8 In a paper in the International Journal of Transgender Health, Cal Horton observed that "[The Review], by design, prioritized cis professionals with no experience in trans healthcare."[28] In Horton's assessment, people consulted by Cass were chosen for their "absence of trans specific knowledge experience, including exclusion of those with lived experience of being trans."[28] The original terms of reference for the Review explicitly stated it "deliberately does not contain subject matter experts or people with lived experience of gender services."[28] This was later amended to a vague note on the exclusion of parties with a "significant interest in the outcome of the Review" (i.e., trans people concerned about their access to care).[28] Cat Burton, who was consulted as director of the Gender Identity Research & Education Society (GIRES), concluded that "it was obvious that the review had been written before we started."[59]

The Cass Review convened several focus groups of "former, current and potential future service users" in Spring 2023.[60] The stated aim was to "understand [the] experiences" of trans youth and to "capture their thoughts and ideas about what they need and want from services and how they would want to access them."[60] Multiple participants in these focus groups have expressed that they felt pressure to "'prove' to clinicians that they were transgender."[2] One stated that clinicians had "probed [them] so hard" for "'alternative' reasons" for their transness, including "childhood trauma, with emphasis on sexual assault."[2] This is an alternative fact propagated by anti-trans advocates,[61][62] like Genspect[63] and Parents of ROGD Kids.[64]

The full membership of the Cass Review's advisory board remains unknown.[65][66] Richard Byng and Richard Stephens of SEGM are known members.[67][68] Finnish child psychiatrist Riittakerttu Kaltiala is another.[69][70] Kaltiala established Finland's youth gender program, which has been accused of "grueling assessments, mockery, misgendering, and intrusive personal questions."[69] A 15-year-old transmasculine patient reported being grilled on his masturbatory habits and told to report back after experimenting as "homework."[69] Kaltiala decried youth transition in Finland's leading medical journal in 2011.[69][71] One of the few studies rated as "high quality" by the Cass Review was a 2020 paper by Kaltiala et al. concluded that medical transition does not "improve functioning and relieve psychiatric comorbidities" in young patients.[11][72] In 2022, Kaltiala testified in support of Florida's ban on gender-affirming care for minors,[73] and she personally introduced Cass to anti-trans Traditionalist Catholic activist Patrick Hunter.[51]

The final version of the Cass Review does not name any of its authors.[74] This contravenes "international publication standards" as outlined in a 2025 paper published in the New England Journal of Medicine (NEJM).[74] The paper's authors, Daniel G. Aaron and Craig Konnoth, concluded that the Cass team "cannot convincingly claim that the intensity of debate" over transgender issues requires them to shield their names, given that the authors of the WPATH standards are known."[74] They further found "evidence of antitransgender bias in invitations to oversee and participate in the report."[74]

Scientific response and general criticism[edit]

Opposition from major medical groups[edit]

Headquarters of the British Medical Association.

The Cass Review has been widely criticised by medical bodies outside TERF Island since its April 2024 release.[3] WPATH|, in a joint statement with its American counterpart USPATH, determined that the Cass Review "relies on selective and inconsistent use of evidence, and its recommendations often do not follow from the data presented in the systematic reviews."[15] PATHA of New Zealand held that the Review makes several "harmful recommendations" and "ignores the consensus of major medical bodies around the world."[75] The American Academy of Pediatrics, the Endocrine Society, the Canadian Pediatric Society, and the Royal Australian and New Zealand College of Psychiatrists have all rejected the Cass Review's findings and recommendations.[76][77][78] The Endocrine Society's statement noted that the Cass Review "does not contain any new research that would contradict" existing clinical guidelines on gender-affirming care for minors.[79]

A report produced by several researchers for Yale's Integrity Project concluded that the Cass Review "levies unsupported assertions about gender identity, gender dysphoria, standard practices, and the safety of gender-affirming medical treatments," and the systematic reviews it relies upon "have serious methodological flaws, including the omission of key findings in the extant body of literature."[11][80][81]

In July 2024, the British Medical Association[note 4] broke ranks with the UK's institutional transphobia,[82][83][84][85] announcing it planned to "undertake an evaluation of the Cass Review" by the year's end.[86] The statement cited international and domestic concerns over "weaknesses in the methodologies used in the Review and problems arising from the implementation of some of the recommendations."[86] The UK's anti-trans commentariat were predictably outraged.[87][88][89]

AI-generated and "borrowed" images[edit]

An AI-generated Adobe stock image of a pink-haired "non binary teen" featured in the Cass Review.[90]

The Cass Review drew criticism for using AI-generated images throughout its final published version.[90][91][92][93] A member of Cass's team confirmed the use of Adobe stock images to both PinkNews and 404 Media.[90][93] In a statement to 404 Media, the team member explained that, given the "sensitive and contentious" nature of the report, a "conscious" effort was made to avoid "images that could identify any individuals."[90]

Machine learning tends to reproduce the biases and flaws of its training model.[94] Reece Rogers of Wired found that AI tools such as Midjourney "universally" produce "stereotypical depictions of LGBTQ culture" in a 2024 investigation.[95] According to Rogers' report, the AI slop machine envisions gay men as "fashionable dressers with killer abs," lesbians with "nose rings and stern expressions," and bi and non-binary people with "textured" purple hair.[95] This is consistent with a 2023 study that found AI outputs represent LGBT people as "less human, more stereotyped and more sexualized."[96] Another study from 2023 found images of non-binary people produced by Stable Diffusion were "farthest from [the] baseline depiction of 'person'" as a white man.[97] The study's lead author, Sourojit Ghosh, told 404 Media that stereotype-laden AI images contribute to the "historic trend" of mainstream LGBT erasure, and implicitly tell young people "there is a 'correct' way to present oneself as trans/nonbinary."[90] Mel Woods of Xtra! echoed this view, warning that such images "flatten down experiences and identities into stereotypes, and suggest there's only one way to be trans."[91] Nonethless, Abigail Anthony of National Review wrote a bizarre defense of Cass's use of AI images, though she conceded that the cover art has "creepy fingers."[98]

The Cass Review also allegedly "borrowed" the chart presented as "Figure 11" (see below) from SEGM's website without attribution.[99] The only modification was the removal of SEGM's logo from the lower right corner.[99] SEGM co-founder Zhenya Abbruzzese[note 5] commented in an Undark interview that the group were "both surprised and pleased" to discover their chart in the Cass Review.[99] The Review's teal-and-orange colour scheme was seemingly inspired by SEGM's graphics.[100]

Methodological issues and unsupported claims[edit]

That the Review asserts that the quality of evidence on which current practice is based is inadequate and then goes on to make recommendations that are based on a lower level of evidence is striking and concerning.
—Vandermorris et al.[7]
The Integrity Project's critical notes on a graph presented in the Cass Review.[11]:16[1]:85 The chart doesn't show an "exponential" increase in GIDS referrals as claimed, but rather linear growth with levelling off, followed by a decrease and an illusory spike caused by double-counting.[11]:16 This chart was seemingly "borrowed" from SEGM without credit.[99]

A brief rundown of everything Cass gets wrong[edit]

The Cass Review and the systematic reviews it drew on repeatedly violated conventional standards of evidence evaluation;[7][11]:8, 28–33 violated what can be surmised of its own standards of evidence evaluation;[11]:2 made some completely unsupported or disproven assertions;[7][11]:19–26[101]:10–11[4]:8[102] botched the use of technical terminology;[11]:8, 15–17 misrepresented/misinterpreted its own presented data;[11]:15–18, 20–21 claimed to oppose conversion therapy while uncritically and favorably citing papers "proposing methods that claim to suppress transgender identity";[11]:20–21 failed to rigorously define or explain its standards or reasoning for evidence quality;[11]:8, 28–33 failed to seriously consider other factors recommended for evaluation in the care of trans patients by e.g. a GRADE approach, such as risk-benefit ratios,[11]:8–10[note 6][4]:8[5] which can be important especially given the limits for achievement of "gold standard" evidence in many types of medicine.[103][11]:10–12[104]

They failed to contextualize transgender medicine within wider pediatric medicine (in such a way as to create an implicit double-standard);[11]:12–15 misrepresented the careful and considered deployment of transgender medicine as instead careless (which ran against the review's own data);[11]:18–19 oversimplified some nuanced findings;[11]:9 framed patients' advancement from social transition to medical transition as though the former caused the latter, rather than this being a demonstration that the patients are genuinely transgender;[11]:19–20 and cited papers based on surveys from anti-transgender websites while ignoring or underplaying major findings from certain papers that were based on much more rigorous methodologies,[11]:22–23[5] including even some papers that the Cass Review's own systematic reviews rated as "moderate" or "high" quality.[11]:37–38 Basically, this means the final report failed to reference certain positive evidence for trans medicine that the review's own evidence-evaluators found.[4]:9–10

Throwing out the majority of research[edit]

Hilary Cass throws out studies that don't confirm her thesis (artistic interpretation).
Steven Novella: If you decide after you look at the evidence what the threshold is--

Cara Santa Maria: Well, that's p-hacking. It's the equivalent of p-hacking. It's not hacking the p, it's hacking something else. It's hacking the threshold. It's post hoc determination.

Steven Novella: Or ad hoc. So rather than: 'here are the established methods that we use to evaluate whether or not the threshold of evidence has been met. And we're going to apply that established standard to this body of evidence.' They did not do that. They violated standard practice.
The Skeptics' Guide to the Universe, Episode #995[105]:39:54–1:08:10[106]

The Cass Review's biggest methodological flaw is its nearly-wholesale dismissal of the existing body of scientific research supporting gender-affirming care.[11][74][107][108] Cass recruited researchers at the University of York to carry out seven systematic reviews (SRs) of the available scientific literature for use in the review.[11] McNamara et al. (2024) found that the York authors preregistered their intent to assess study quality in all seven SRs using the Mixed Methods Appraisal Tool (MMAT).[11] However, they ultimately switched to a version of the Newcastle-Ottawa Scale (NOS) with "several adaptations" introduced by themselves for half[101] of the SRs, which McNamara et al. judged to be "a divergence from standard practices designed to minimize bias in systematic reviews" and "not a minor one." This switch was not explained or acknowledged in the SRs.[11]:28–29

The SRs excluded all research not published in English and grey literature from consideration.[11]:33[74] Of the 103 studies reviewed by the SRs, "only 2 of 51 puberty-blocker and 1 of 53 hormone studies [were found] to be high-quality."[74] The BMJ Group put out a press release boasting about this fact after the SRs were published in Archives of Disease in Childhood.[109] Applying ROBIS, a tool recommended by Cochrane for evaluating risk of bias in systematic reviews, all of the seven systematic reviews used by the Cass Review were determined to be at a high risk of bias on every single measure (of four measures) — except for one that was low risk of bias on a single measure.[11]:31–32[101]:3–5 This was "driven by unexplained protocol deviations, ambiguous eligibility criteria, inadequate study identification, and the failure to integrate consideration of these limitations into the conclusions derived from the evidence syntheses."[101]:2

In laymen's terms, this means the Cass Review applied incomprehensible standards to its evaluation of evidence, seemingly picking-and-choosing what studies to include and exclude on an arbitrary or selective basis. This is worse than the explanation that the Review dismissed everything but double-blind randomized controlled trials (RCTs) as "low quality." That misconception has made its way into media coverage and popular commentary.[107][108] RCTs have limitations and may be ethically questionable or practically infeasible in certain fields, including chemotherapy, abortion medication, and gender care.[11]:12-13[108][note 7] As McNamara et al. explain, "the presence or absence of 'high-quality evidence' alone should not be used to decide whether to offer treatment" with proven benefits, since "RCTs specifically are ill-suited to studying the effects of many interventions" on trans people's well-being.[11]:12 In the case of puberty blockers, it would be impossible to successfully conduct a double-blind RCT on their efficacy in treating gender dysphoria in trans adolescents, as the placebo cohort would realise their lot upon experiencing unwanted body changes (e.g. breast development in trans boys).[11]:12-13[108][110] Half of the drugs used in pediatric medicine are prescribed "off-label on the basis of limited evidence."[74] This is due to a general lack of pharmaceutical research focusing on children.[74] The overall prevalence of pediatric RCTs has declined or stagnated since the 1980s for various reasons.[111][112][113]

The Cass Review's recommendations were changed without notice in December 2024 (including in the original PDF) from supporting an informed-consent framework to waffling that this "model may be used" while doctors consider "different treatment options that may meet the patient's needs."[114]

Weird, ridiculous, and harmful assertions[edit]

The Cass Review suggests little girls like dollies for biological reasons.
  • Toy preferences are biological: The Cass Review claims children's "toy preferences, play, and physicality" are "influenced by biological and social factors."[1]:98 It asserts that "there is evidence for [strong] prenatal and postnatal hormonal influence" in girls' apparent preference for dolls and boys' preference for trucks,[1]:100–101 but that this is somehow not also the case for gender identity[1]:101,115 despite there being evidence for that,[115] including evidence mentioned in the Cass Review itself (though it frames prenatal sex hormones in this case as "environmental influences" for some reason).[1]:115–116 It cites a 2015 study by Melissa Hines,[1]:101 who also co-authored a 2002 study claiming "sexually differentiated object preferences" in vervet monkeys.[116][117] In other words, it claimed that male vervets showed greater interest in a "car and a ball" while females preferred the "doll and [cooking] pot," a finding that assumes animals understand the purpose of human-made objects.[116][117] A later, smaller study with rhesus macaques had different findings from Hines's,[118] so it might even depend on the species of primate. (Humans are most closely related to bonobos and chimpanzees, which differ behaviorally, being matriarchal and patriarchal respectively.[119][120])
  • Porn makes kids trans?: The Cass Review suggests "more investigation into consumption of online pornography and gender dysphoria is needed."[1]:110 The only source it cites to prove the supposed need for such research is a 2024 commentary by Karin Nadrowski.[1]:110 Nadrowski argues that exposure to violent, degrading porn may induce transness in AFAB youth by increasing "shame and fear of becoming a woman," claiming that "working through" patients' sexual trauma "may correct false beliefs about gender inequality and therefore might alleviate gender dysphoria."[121] Nadrowski, a clinical psychiatrist and detransitioner, belongs to a pro-conversion therapy lobby group.[122][123] Cass stated in a May 2024 interview with NPR that "early exposure to pornography" may drive trans identification among AFABs.[122][124][125]
  • Tumblr makes kids trans?: The Cass Review stops short of endorsing the debunked concept of rapid-onset gender dysphoria (ROGD) as fact.[note 8] However, the Review makes a point of concern trolling that some of the parents it consulted were worried about online "influencers," who they believe have exerted "a substantial impact on their child's beliefs and understanding of their gender."[1]:120[note 9] It does this after spending several pages fretting over whether social media and smartphones have increased the incidence of depression, sleep disorders, and body-image issues among young people.[1]:109-111 The notion that trans identities are spread via "social contagion" has been popularised by Abigail Shrier's Irreversible Damage.[44] A colleague of Hilary Cass has alleged that she "strongly recommended" this book to him in 2020.[34]
"Under 25? Therapy only." The UK anti-trans group Our Duty calling for restrictions on adult access to gender care in 2020.
  • 24-year-olds are children: The Cass Review states that there are "different issues involved in considering gender care for children and young people than for adults."[1]:26 In the following sentence, it claims that a person's "developmental trajectory [...] continues to their mid-20s," which it maintains "needs to be considered" in regards to supposed "determinants of gender incongruence."[1]:26 In a later section, it states that brain maturation progresses into the mid-20s, and that "gender and sexual identity may continue to evolve" during this time.[1]:193 Cass thus relies on the fallacious idea that human brains aren't fully developed or mature until age 25.[126] This notion, rooted in neurological research showing that white matter in the prefrontal cortex generally increases into the 20s, has become a pop-psych explanation for everything from school shootings to Leonardo DiCaprio's love life.[126] The Cass Review proposes creating a "follow-through service" for NHS gender patients aged 17 to 25.[1]:224 It suggests this would "remove the need for transition at this vulnerable time."[1]:224 It's unclear whether this refers to the oft-abrupt transfer from GIDS to adult services or the process of gender transition.[127] Anti-trans lobby groups Genspect[128][129] and Our Duty[130] support bans on gender-affirming care for under-25s. Genspect director Alasdair Gunn advised "focus[ing] relentlessly" on the "problem" of under-25s transitioning for strategic reasons in chatlogs leaked in 2023.[131]
  • Autistic people cannot know themselves: The Cass Review states that research has found "transgender and gender-diverse individuals are three to six times more likely to be autistic" than cis people.[1]:93 The cited study, Warrier et al. (2020), did indeed reach this conclusion.[132] At least one other paper supports a link between gender variance and neurodivergence.[133] The trouble lies in the Review's suggestion that issues with sensory processing and emotional expression mean autistic trans kids cannot be trusted to accurately articulate "how they are feeling about their internal sensations, their gender identity and their sexual identity."[1]:93 It uncritically repeats a 2011 study's assertion that "it can be complicated to disentangle" whether autistic trans kids' dysphoria "evolves from a general feeling of being just 'different' or a whether a true 'core' cross-gender identity exists."[1]:68[134] The Nadrowski paper more bluntly opines that the "reduced mentalization capacities" of AFAB autistics make them more vulnerable to being transed by porn.[121] The Cass Review recommends screening young NHS gender patients for "neurodevelopmental conditions, including autism spectrum disorder."[1]:148 Its claims are part of a wider ableist assault on autistic people's right to self-determination. Trans autistics have reported being delayed or blocked in accessing care by clinicians.[135] Several U.S. states restricted or banned gender-affirming care for autistics in 2023.[136]

Political context and impact[edit]

Puberty blocker ban[edit]

Health Secretary Wes Streeting.
The BMA has been critical of proposals to ban the prescribing of puberty blockers to children and young people with gender dysphoria, calling instead for more research to help form a solid evidence base for children’s care – not just in gender dysphoria but more widely in paediatric treatments. The Association believes clinicians, patients and families should make decisions about treatment on the best available evidence, not politicians.
—British Medical Association[86]

Puberty blockers were banned for gender dysphoria patients under 16[note 10] in the UK following the High Court's decision in Bell v Tavistock in December 2020.[138][139] The decision was overturned by the Court of Appeal in the September 2021.[140] In May 2024, shortly before the dissolution of Parliament ahead of that year's general election, Tory health secretary Victoria Atkins announced a ban on new blocker prescriptions for dysphoria patients under 18.[141][142][143][144] The surprise move exploited an emergency legal mechanism that was last invoked in 1999 to ban a poisonous herb (Aristolochia) used in traditional Chinese medicine following two deaths.[143][144][145] TransActual and the Good Law Project quickly mounted a legal challenge of Atkins' ban, arguing she hadn't shown a "serious danger to health" that justified emergency action.[146][147] A judge held that Atkins' use of emergency powers was "lawful" in late July.[148][147]

The ban would've automatically expired in September 2024 given the mechanism's emergency intent.[141][142][143] Wes Streeting announced his plan to make the ban permanent within days of his instalment as health secretary under the newly-elected Labour government in early July.[149][150] The "temporary" ban was extended on August 22.[151][note 11] Sinn Féin implemented the ban in Northern Ireland soon after.[154][155] The "temporary" ban was extended a second time in November.[156][157] The ban was made indefinite in December in all regions of the UK.[158][159][160][161] It will be "reviewed" in 2027 following the (presumably pre-written) findings of a government-run "clinical trial" that kids seeking GAC in the UK will be funnelled into going forward.[162] As of September 2024, the Cass Review had reportedly been cited for bans in ten U.S. states and one Canadian province, despite this seeming to go beyond even the review's own published recommendations.[4]:10[163]

Blockers remain legal in the UK for the treatment of precocious puberty (i.e., they're fine for cis kids, but not for trans kids).[164][4]:6 In a letter to a Labour constituent, Streeting claimed that suppressing "abnormally high" hormone levels in young children has been "extensively tested" and meets "strict safety guidelines," but that "stopping the normal surge of hormones" at puberty might be bad for nebulous reasons involving "psychological and brain development."[165] A subsequent FOI request offered no answer as to whether Streeting had examined evidence or consulted experts on the safety of precocious puberty treatment before making these claims.[153] According to an academic paper in the Journal of Paediatrics and Child Health:

The same puberty blockers have been utilised since 1981 for treating central precocious puberty, and their use is now considered safe and effective, with no known severe long-term adverse effects. They have been licensed for central precocious puberty based on relatively short open-label studies with small groups of patients because it was impossible and unethical to perform more robust studies (i.e., randomised controlled trials). Limited evidence exists, for example, on their psychological outcomes in children with central precocious puberty. If we aspire to the same scientific rigour as Cass review then, by the transitive property, we may well consider ceasing the prescription of puberty blockers also in children with precocious puberty. …
Puberty blockers have been the standard of care for many years in different countries when applied in well-staffed certified centres with high-quality multi-professional teams, and it is very unusual in the history of medicine that a time-honoured treatment, with a good safety record, even if based on non-randomised trials and experts' opinion, is simply banned, while waiting for better evidence.
—Ludovica Barbi and Gianluca Tornese (2024)[104]

Alleged suicide coverup[edit]

Barrister Jolyon Maugham revealed in June 2024 that multiple whistleblowers had come forward with allegations of a "huge increase" in trans youth deaths since Bell v Tavistock.[166] According to one whistleblower, there were 16 deaths of trans youth on the NHS waiting list in the three years after Bell, in contrast to only a single death in the seven years before the decision.[166] This whistleblower brought these alarming numbers to the attention of Hilary Cass and a director of the Tavistock clinic.[166] When Maugham contacted Cass about the whistleblower's claims, a representative replied pointing him to a section of the Cass Review that references "deaths of patients," but attributes suicides to those with "multiple comorbidities and/or complex backgrounds."[166] A second whistleblower alleged that Tavistock staff who planned to expose the numbers in an open letter were threatened with "disciplinary proceedings and being reported to their regulatory bodies."[166]

Maugham's revelations prompted the UK government to hastily commission an "independent review" from University of Manchester psychiatry professor Louis Appleby.[167][168][note 12] Appleby's review concluded that "the data do not support the claim" of a "large rise in suicide" among Tavistock patients.[167][168] In response, Maugham pointed out that that Appleby's review examined suicides among "current and former GIDS patients," while the whistleblowers' claims concerned those stuck in waiting-list limbo.[168][173] Trans people seeking gender-affirming care through the NHS face years-long waitlists.[174][175] In August 2024, a 17-year-old trans man who spent four years on the GIDS waiting list without an appointment told The Guardian that trans youth were "being used for political gain and treated as an intellectual exercise, rather than as human beings."[176] Another young trans person who resorted to DIY hormone therapy after waiting five years stated that she "had to become [her] own doctor."[176] The Labour government directed kids "unsure how the ban applies to their circumstances" to a list of crisis hotlines in its August 22 announcement.[151][177] Caroline Litman filed a FOI request to learn her daughter Alice's widely-reported suicide was not included in Appleby's review.[178][note 13] Cass told The Times in December 2024 that it was "irresponsible for people to shroud-wave" over trans youth suicides.[179][180] This merely insults people as "irresponsible" for criticizing the government's policy that resulted in deaths.

In a 2024 survey by researcher Natacha Kennedy, parents of trans youth in the UK reported that their children experienced "sharply declining mental health, increased depression, social isolation, anxiety, stress, self-harm, attempts to avoid school and suicide ideation" following the blocker ban.[181] This is consistent with other past research into the impacts of anti-LGBT government policy on mental health.[5] Another 2024 study found a 72% increase of suicide attempts among trans and non-binary youth (TGNB) following the enactment of anti-trans legislation in several U.S. states.[182] The American study noted "the lack of an observable anticipatory effect in the time periods leading up to the enactment of the laws," proposing that this may be due to the long, bureaucratic legislative process "diffus[sing] the effects the bill debates had on the mental health of TGNB young people."[182] Clinicians have also expressed concerns over the impact of anti-trans laws on the treatment of eating disorders (EDs) among trans youth.[183] These young people may fall into "harmful eating behaviors" to "make their bodies conform to a masculine or feminine ideal," with trans boys in particular seeking to end menstruation or delay its onset through malnutrition.[183]

See also[edit]

External links[edit]

Notes[edit]

  1. The LGB Alliance told its followers to "buy the book" and "tell everyone [they] know" in a June 2020 tweet. It seems likely that imported American copies were already in circulation in the UK by that time. It's also possible that people may have received advance copies of the Swift Press edition prior to its publication.
  2. Shrier made a number of extreme and scientifically-unsupported claims in Irreversible Damage. For example, she recommended that parents with trans sons prevent them from accessing smartphones,[45]:236 suggesting they go "to great lengths to physically move their daughters away from the schools, the peer groups, and the online communities" that supported their gender expression and identity.[45]:240–242 Shrier also compared gender transition to trauma inflicted on Jewish children during the Holocaust.[45]:113–114
  3. Genspect is also designated a hate group by the SPLC.[56]
  4. The systematic reviews produced for the Cass Review were published in Archives of Disease in Childhood. This is one of several journals belonging to the BMJ Group, publisher of the BMA's trade magazine, the British Medical Journal, which maintains editorial independence. This editorial independence has grown increasingly apparent in recent years, as the BMJ has become an outlet for fringe ideas on trans healthcare, while the BMA's policy positions have reflected scientific consensus.
  5. Evgenia "Zhenya" Abbruzzese is reportedly the mother of terminally-online detransitioner Maia Poet. The younger Abbruzzese told the New York Post in February 2025 that she decided there are "more important things in life than my gender dysphoria" because she was living as a trans man in Israel on October 7, 2023, and would've attended the Nova Music Festival if she and her friends could've afforded tickets and secured transportation.
  6. Quoting McNamara et al.: "The Review does not consider the harms of not offering gender-affirming medical care to a young person with gender dysphoria. The most concrete and tangible effect of not providing treatment is the development of permanent physical characteristics that do not align with a person’s gender. These include voice deepening, hair growth, breast tissue development, final height, or body habitus. The Review ignores the significant psychological pain suffered by patients with gender dysphoria, for whom these permanent physical changes are highly distressing. The Review also ignores the consequences for teens who, left untreated, must present to the world a physical appearance that is at odds with their own identity. In adulthood, these physical effects can be ameliorated to some degree with costly and invasive treatments such as surgery, hair removal, and speech therapy. These treatments do not erase the intervening years of psychological distress. The Review also selectively identifies the purported harms of treatment while failing to engage with the harms of no treatment. For example, the Review theorizes that those who have been treated with puberty-pausing medications and wish to pursue vaginoplasty may have a more challenging postoperative course. But the Review does not consider how puberty-pausing medications prevent development of unwanted breast tissue and can prevent the later need for mastectomy, which is a commonly sought surgery by transgender adults."[11]:9–10
  7. This doesn't disqualify RCTs from being used in the listed fields with appropriate ethical safeguards. When testing the effectiveness of a treatment, a placebo is generally used as a control in RCTs. However, when RCTs are done for new treatments for which withholding of treatment would be considered unethical, the control group usually consists of a currently proven treatment instead. Cancer treatment is a perfect example. RCTs are common in cancer research. However, instead of using a placebo for the control group (as withholding treatment for a disease with such a high rate of death would be unethical), the control group generally receives the same kind of treatment they would expect from your average hospital. It's still an RCT, but the C is slightly different, with no ethical qualms.
  8. It does cite a 2021 survey by Lisa Littman, author of the earlier paper proposing ROGD, in a section on respondents' stated reasons for detransitioning.
  9. The sentence initially attributes these concerns to "gender-questioning young people and their parents" before the Review tips its hand with "their child."
  10. This is the legal threshold for minors giving informed consent to medical treatments in the UK under the principle of Gillick competence. However, since most adolescents go through puberty well before ages 16 to 18, restricting blocker access to older teens represents a total ban for most patients in practice. Blockers are completely useless[137] to trans kids who've already been through puberty. They will not allow a trans girl to ungrow facial hair. Keira Bell, the plaintiff in Bell v Tavistock, is a political detransitioner like Chloe Cole. Bell was prescribed blockers at 16 and underwent top surgery at 20.
  11. This time with the added cruelty of closing two loopholes that allowed 1) importation of blockers prescribed and supplied in the European Union and 2) UK doctors to take over existing prescriptions from the EU. Jolyon Maugham has stated that these oversights suggest that Atkins' ban was drafted in "great haste."[152] Streeting chose to extend the ban on the day it was announced.[153]
  12. Professor Appleby, an expert on suicide prevention,[169] allegedly follows Rosie Duffield on Twitter. Duffield is a stridently anti-trans[170] Labour MP caught face-palming in response to SNP MP Kirsty Blackman mentioning a trans constituent's suicidal thoughts in a parliamentary speech.[171] Appleby also reportedly follows several "transphobic troll accounts"[172] with names such as "Unafraid Woman."
  13. Alice Litman, a 20-year-old trans woman from Brighton, took her life in May 2022 after spending 1,023 days on the waiting list without a first appointment. Her death prompted an inquiry in which a coroner determined that languishing on a waiting list for nearly three years "contributed to a decline in her mental health." The coroner concluded that Alice's transition from children's to adult services was "non-existent," remarking that, "it seems to me that shortly after Alice turned 18, she was offered a 'coping strategies' course in a quite frankly half-hearted final offer of some kind of support."

References[edit]

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    Quoted poster (@ripx4nutmeg): "On Real Time with Bill Maher, Abigail Shrier is asked why England has taken a global lead when it comes to banning puberty blockers for children confused about their gender[sic].

    She says that there are two reasons: A centralised NHS and JK Rowling's support for gender critical feminists"

    Kemi Badenoch (@KemiBadenoch): "The third reason was having gender-critical men and women in the UK government, holding the positions that mattered most in Equalities and Health.

    You only need to look at what the SNP did in Scotland to see what would have happened had we not intervened.

    The Cass Review would **never** have been commissioned under a Labour govt. Labour did not want to know.

    We had incredible opposition from the system on everything. It was when the ministers changed that everything changed."

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  35. Twitter thread by Max Davie (@maxdavie). Archived copies of constituent tweets: 1, 2, 3, 4, 5, 6, 7, 8.
  36. Listing for the hardback edition of Irreversible Damage on Amazon.
  37. Listing for Irreversible Damage on the Swift Press website.
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