“The adoption of a treatment with uncertain benefits without further scrutiny is a significant departure from established practice.”
The Cass Review, s23, p25
The above statement encapsulates what went wrong with children’s gender services at the Tavistock Centre Gender Identity Development Service (GIDS). This admission that the Dutch Protocol was pursued bypassing established practice and ignoring inclusion criteria (mentally unwell patients should have been excluded) sets the tone for the final report of The Cass Review.
The NHS is cognitively captured by gender identity ideology. Working in such an environment, surrounded by staff who put their quasi-religion before science, must be near impossible for any clinician dedicated to following the evidence. For this reason, we must commend the work of Dr Hilary Cass in producing a report which, while underwhelming, has made the NHS materially safer for children with transgender ideation. Yet all the while the medical pathway remains an option, it is still not safe enough for parents to entrust with their children.
Our Duty has been sceptical of The Cass Review process since the outset, and with the publication of the Final Report, much of our scepticism has been shown to be justified. However, there were a few areas where our admittedly low expectations were exceeded.
In particular, we expressed our concerns to Dr Cass that the terms of reference for her review conflicted with the NHS Long-Term Plan for Mental Health which lays the groundwork for adolescent services being provisioned to age 25. Furthermore, we expressed the fears of the parents we represent that their vulnerable children could be passed on to the highly dangerous adult services as young as 17. We were, therefore, relieved to see that our concerns in this regard had been accommodated. In addition, we welcome the call for a review of the adult services.
“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”
The Cass Review, Recommendation 23, p42
“Given that the changing demographic presenting to children and young people’s services is reflected in a change of presentations to adult services, NHS England should consider bringing forward any planned update of the adult service specification and review the model of care and operating procedures.”
The Cass Review, Recommendation 24, p42
We note that NHS England has instigated such a review.
In another positive, the report makes clear that the clinician takes responsibility:
“The clinician carries responsibility for the assessment, subsequent treatment recommendations and any harm that might be caused to a patient under their care. They need to define as clearly and reproducibly as they can exactly what condition they are treating to be accountable for their decisions on the options offered to the patient.”
The Cass Review, s57, p29
It is hoped that this will make at least some of the myriad rogue practitioners think twice before prescribing wrong-sex hormones to same-sex attracted, autistic youth.
In April, 2023, following a meeting with Dr Cass, we raised our concerns as to the direction of the review at that time. We shall revisit these to establish what issues remain to be addressed:
‘True trans’. We said that there was a risk that the Cass Review may perpetuate the myth of the “transgender child”. This has been borne out:
“there is a need for all clinicians across the NHS to receive better training on how to work sensitively and effectively with trans, non-binary and gender-questioning young people.”
The Cass Review, s120, p38
There is frequent mention in the report of “individuals for whom medical intervention is clinically Indicated” – medical gender interventions are never clinically indicated, and it is a gross omission of the report that this fact was not established from the combination of evidence and medical ethics that were available to it.
Trans homogeneity. We were concerned that the interim review did not consider the various cohorts nor their constituent members to be heterogeneous. We are pleased to see that this concern was addressed in the Final Report.
“They are a heterogenous group with wide-ranging co-occurring conditions, often including complex needs. This needs to be reflected in the services offered by the NHS.”
The Cass Review, 5.69, p97
No specialist treatment. The Final Report did document the requirement to treat specific comorbidities. In addition, the role of parents in supporting their children (which is the preferred course of remediation) was highlighted. The review has addressed our concerns in this regard, and we look forward to seeing the new specialist services emerge. We consider that the work we do in empowering families to navigate having a child with transgender ideation to be worthy of NHS support, too.
Realm ignorance. We predicted that there will be no recognition of transgender ideation and how best to treat it.
While we submitted our model to the Cass Review over a year ago, we can only assume it was discounted as “opinions unsupported by adequate evidence”. Which is a shame because it was developed out of years of real work with affected parents untainted by ideological fervour. There is not one mention of transgender ideation in the report, while concepts like gender dysphoria and gender incongruence are used as if they are givens.
The word ‘rumination’ a key ingredient in adolescent transgender ideation and the development of dysphoric feelings does not appear once in the whole report.
Cultural blindness. There was no recognition that the NHS is ideologically captured by gender theory. Consequently, there were no recommendations on cleaning up its organisations and training ecosystem. Institutional inertia and recycling of corrupt staff have the potential to perpetuate the status quo. The evidence of the gender rot seeping into this allegedly independent review is plain to see when ideological terms like ‘cisgender’ are used and the concept of ‘gender identity’ is unquestioned:
“the role of the clinical team is to help them address some of these complex issues so that they can better understand their gender identity and evaluate the options available to them.”
The Cass Review, 8.62, p122
Following fashion. There seems to be an acceptance of the idea that this generation is more accepting of trans identities and that justifies providing the means for people to get them. The Cass Review seems unaware that the generational difference is almost entirely due to indoctrination in schools.
“The generational changes in understanding and beliefs about the mutability of gender form the basis for many young people’s understanding of their own experiences and the experiences of those around them.”
The Cass Review, 8.46,p120
Young people’s indoctrination into the cult of gender should not have had a greater influence over this review than the wisdom of loving parents.
The Cass Review gave more credence to the opinions of those craving validation than it did to those craving the safety of their children. At the outset of the review it was clear that a foolhardy quest for consensus had been undertaken. Objective truth allied with robust ethics would have been a better goal.
When the Cass Review was established, it was done so with the stated objective of finding consensus.
“Consensus is the process of abandoning all beliefs, principles, values and policies in search of something in which no one believes, but to which no one objects.”
Margaret Thatcher.
What this meant in practice is that the review team were obliged to consult groups like Mermaids while at the same time examining the evidence. These are two wildly conflicting sources. The influence of people with transgender ideation (whose opinions are clouded by a craving for validation) is both unwarranted and plain to see. This is no more evident than when the report elevates what patients want over and above what they need.
The desire to conduct and assemble research such that the report can substantiate its conclusions is commendable. However, in the 4 years that have passed, there would have been, should have been, scope to include new research into the work being done by emergent organisations; particularly Our Duty which has developed expertise in the field that is safer and less intrusive than that on offer from the NHS. It is our view that the review would have benefited from much greater involvement from Our Duty, either via the University of York research programme or directly.
This review, which can justly be characterised as too little, too late, must be seen as merely the start of a process to introduce evidence-based medicine and objectivity to the NHS. Dr Cass has succeeded in gaining acceptance from, amongst others, the Labour Party and Stonewall for her review, and given the toxic tribalism that clouds this subject area, those endorsements might well justify the halfway house we have arrived at.
Nevertheless, we must remember that there was a failure of governance at the Tavistock and Portman NHS Foundation Trust. Had the concerns of whistleblowers and parents been heeded in the Autumn of 2019 we would not still be waiting for the NHS to get its house in order nearly five years later.
