Mrs Benn

This week saw the publication of the Cass Review, an independent review of the treatment of gender-questioning young people in the UK by the eminent paediactrician Dr Hillary Cass. The review has been received rapturously by the right-wing media, with the Daily Mail proclaiming that it had once and for all exposed the dangerous ideology that was driving young people to identify as trans. Even the Observer – a traditionally liberal paper – joined in, with an editorial slamming the National Health Service (NHS) for allowing ideology to trump evidence.

However, the review itself (which I read over the weekend) is not primarily concerned with ideology. Dr Cass is a paediatrician and her report is written from the perspective of a clinician making recommendations about how best to deliver care to young people. Her report draws upon data from a variety of sources, including published scientific literature and reports and policy documents produced by healthcare providers and bodies around the world who are responsible for the delivery of care to gender-questioning young people. Although the Review was commissioned in the wake of a heated debate about the treatment of gender-questioning teenagers, it addresses the scientific, medical and ethical issues around the care of young people and is not primarily concerned with “trans ideology”.

Whole People

The Review is not primarily a technical document, being focussed rather on policy, and it provides quite a lot of helpful background material. For example, it explores arguments for and against the existence of a biological basis for gender dyspohoria (something that I have written about elsewhere), before concluding that there is no conclusive evidence for such an explanation at present. It also explores how the rise of social media, online pornography and other factors may have driven an explosion in the number of young people presenting as gender-questioning. These reflections are very relevant, and to me at least reasonable, although they are not strongly evidence-based.

An important methodological decision was made to focus attention on Generation Z. From one perspective, this seems reasonable: young people currently passing through clinics are from this generation. Moreover, there has been a dramatic growth in the number of young people presenting as gender-questioning, and there is an urgent need to understand where this comes from (as I wrote in 2018). Something is going on, but what? However, the heavy focus on Gen Z in particular has other consequences, to which I return below.

Cass draws the conclusion that Generation Z have been influenced by a multitude of new factors, including growing acceptance of gender variance; the rise of the internet; the pervasive influence of online pornography and the accompanying misogynistic violence; and the explosion of social media. A consequence of these multiple and typically co-occurring influences is that young people with a variety of mental health problems also often additionally identify as trans; many of these young people are being treated primarily as gender-questioning, when, Cass argues, it may be that other problems are the foundational ones. Her concern is that gender incongruence may for many of them be a symptom rather than a cause of mental distress.

I have no professional competence to evaluate this assessment. However, it seems that Cass’s main recommendations – that gender questioning young people should be seen quickly, rather than forced to wait for lengthy periods to see a clinician, and that they should be treated as whole persons, and all their needs evaluated – are founded in common sense. Nobody will be disadvantaged by such an approach, and she feels very strongly that it is lacking at present.

Transgender Ideology vs Evidence-Based Medicine

Cass expresses serious concerns about the failures of the NHS to address the needs of gender questioning young people in a timely manner. For example, the Review describes numerous accounts from clinicians that social transition has already taken place for many of their patients before they see them – a problem that results from long waiting lists rather than the capitulation of clinicians to ideology. It is of course possible that “ideological” pressures, whether online or through peer pressure, may have played a role in encouraging young people to undergo social transition, but that is not a result of the capitulation of clinicians to ideology. The report records reports that when many young people are eventually seen by clinicians, they have been living “in stealth mode” for some time and they are desperate to be prescribed puberty blockers to avoid being outed as trans.

What the report does do very effectively is to unpick the many complex, interconnected influences on gender-questioning young people. It makes the case powerfully for rapid referral of gender-questioning young people to clinicians so that they can enter a clinical pathway based upon evidence-based approaches before patterns of behaviour become entrenched.

Moreover, it also places its analysis in an international context. The UK is not unduly rapid – compared to other European nations – in starting young people on hormone treatments. Practice in the UK has adopted approaches pioneered in the Netherlands, in which puberty blockers are prescribed at Tanner Stage 2 in puberty. Summarising a review of international practice Cass comments

“The majority of guidelines recommend waiting until a child has reached Tanner Stage 2 of puberty. The Swedish guideline recommends Tanner Stage 3 (p. 174)… The Swedish and Finnish guidelines differ from others in recommending that puberty suppression should be provided under a research protocol or the supervision of a research clinic (p.175).”

Cass notes that approaches in Finland and Sweden are more measured, and recommends that the UK also develops a more hesitant approach to prescribing puberty blockers. Not only is puberty often well underway when these drugs are prescribed, but there are growing concerns about the impact that they may have upon other aspects of development (for example, development of the brain).

The substantial point here concerns not the role of ideology but the absence of proper clinical evidence to support current practice in the use of puberty blockers, both internationally and in the UK; in other words, treatment protocols in the UK reflect a broader, international lack of evidence-based approaches, not that clinicians in the UK have caved in to ideology.

Cass notes that 98% of those who begin puberty suppression in the UK progress to masculinising/feminising hormones. She expresses concern that while one of the reasons for use of these drugs is to “buy time” for thinking about transition, they appear to lead inexorably to a full transition. Cass makes the point rather forcefully that randomised control trials are lacking for these powerful drugs, and that where people enter on a course of treatment believing that it is good for them, they are apt to believe that the consequences are beneficial, whether or not they in fact are. However, it is not at all clear how one could carry out a randomised control trial for puberty blockers. In pharmaceutical trials, this is done via the administration of a placebo to some of the participants, and it is important that the participants do not know whether they have received the placebo or the candidate drug. In the case of puberty suppression, it will become obvious to members of a placebo group that they are not being treated with hormones. So the alternative, which Cass recommends, is to set up a more complex kind of trial, in which mental health outcomes are analysed over an extended period and in a rigorous fashion. It is important to note that Cass recommends trials into the use of puberty blockers; she does not recommend their abolition as a therapeutic tool, although this is the impression that has been given widely by media.

Is Gender Dysphoria Real?

A weakness of the Cass Review is that childhood gender dysphoria remains comparatively unexplored as a condition. In large measure, this is because of the methodological decision, noted above, to focus on Generation Z. Cass is concerned that gender distress often presents with a variety of co-morbidities, and she is concerned that a failure to explore all of the gender-questioning young person’s needs may drive them down a treatment pathway that associated undue weight to gender issues, to the detriment of treatment of the other conditions.

The argument in favour of considering the patient as a whole person is made powerfully, but a consequence of the way that this positive message is articulated is that it conveys the impression that childhood gender dysphoria may be largely explicable in terms of conditions that co-exist with gender distress. I don’t think it is Cass’s intention to convey this impression. However, she says very little about childhood gender dysphoria, and its progression from childhood to maturity, or what successful outcomes might look like later in life, or the lived experiences of gender dysphoric people. Quite a lot is said about the co-occurrence of gender dysphoria with autism spectrum disorder (ASD), and while this is well-documented, it nevertheless creates the impression that gender dysphoria may largely be explicable in terms of ASD.

The report covers the development of gender comparatively briefly, on pp 98-102, noting that sex differences are expressed in gender role behaviours, gender identity and sexual orientation, and that all three may be influenced by a variety of factors. However, the remainder of Chapter 6 and all of Chapters 7 and 8 is focussed very heavily on development in adolescence. Figure 27 on page 121 presents a schematic diagram summarising the causal factors for gender incongruence which seems to presuppose an onset in adolescence. Even the transphobes’ favourite sexologist, Ray Blanchard, identifies childhood gender dysphoria as a real condition (and differentiates it from adolescent-onset dysphoria), as I have described elsewhere.

Now, if Cass is right, and the explosion in numbers of young people coming forward after puberty for treatment for gender incongruence is associated with a surge in post-pubertal expression of gender dysphoria, this way of thinking is clearly helpful. But what of children for whom gender dysphoria developed much earlier? It is important to note that Cass gives no evidence that she believes such people do not exist, or that they do not matter, but an unfortunate consequence of the way that the report is constructed, and of the fact that this group of people is not addressed explicitly, is that the impression is given that gender dysphoria is largely explicable as an ideological trend. Cass herself says (p. 121):

“There is broad agreement that gender incongruence is a result of a complex interplay between biological, psychological and social factors. This ‘biopsychosocial’ model for causation is thought to account for many aspects of human expression and experience including intelligence, athletic ability, life expectancy, depression and heart disease.”

This is a carefully constructed sentence that in fact leaves open a rather diverse set of explanations for gender dysphoria. The following paragraph from p. 122 is illustrative:

“Although we do not have definitive evidence about biological causes of gender incongruence it may be that some people have a biological predisposition. However, other psychological, personal and social factors will have a bearing on how gender identity evolves and is expressed.”

The origins of gender dysphoria are complex and only poorly understood, and there is no doubt that Cass is reflecting this in what she writes. However, I found it hard to see how the diagram in Figure 27 captured my own experience: I was not aware of a cultural lens or social stress as a causative agent; my sense of difference set in long before puberty; I grew up many years before the invention of the internet; and the transgender narrative was unknown to me – through my childhood I was, for all I knew, the only child who felt the way I did. But the sense gender dysphoria that has been with me for as long as I can remember has had profound implications on my growth and development on a person.

I think this is an unintended consequence of the way that the report is constructed. However, those on the far right who are engaged in the Culture War have already begun trying to repurpose the Cass Review as a demonstration that gender dysphoria is an ideological construct. There has been an explosion of bile; it feels as though the publication of the Cass Review has been seized upon by transphobes everywhere as an incitement to vilify and belittle of trans people. It is hard to find fault with any of the recommendations made in the Cass report itself. Moreover, the report is throughout sympathetic to people suffering from gender incongruence. My concern is merely that the report leaves itself open to repurposing for the purposes of hate by those with an agenda. The dangers inherent in this have been laid out very forcefully by Freddy McConnell in a piece in the Guardian.

Conclusion

The primary focus of the Cass Review is on the delivery of high quality, evidence-based clinical care to young people. It makes a number of recommendations about how to deliver this care, and it stresses the importance of treating gender-questioning young people quickly, and in such a way as to respect all of their needs. Implementation of the recommendations in the review will require additional resources; one of the problems faced by those in the NHS dealing with gender identity is that they are supported very poorly. It remains to be seen whether the Government will act on these recommendations. However, it is important that the Review is not rallowed to be epurposed in the Culture War to legitimate the view that childhood gender dysphoria is an ideological construct, a hypothesis for which it provides no support.