A photo of a pen and a stethoscope on a medical chart to represent The Cass Review

The Cass Review has now been released in full and has already attracted widespread condemnation from women’s, LGBTQIA+ and other equality focused groups. The document makes 32 recommendations and in this piece we take a little tour around what is recommended by The Cass Review.

The Cass Review is, to say the least, kind of underwhelming. For all of it’s many, many, many academic faults that show clear signs of contempt for trans youth and work to install the implication that cisgender outcomes are just better than transgender ones at the highest levels of healthcare, it really hasn’t stuck the bigot landing. It’s a dud.

Criticisms online have mostly focused on the research body used to justify what is recommended by The Cass Review. There is a lot to criticise as impossible standards of evidence are called for, unethical approaches are considered and the bar is set uniquely high for transgender youth in particular.

But I don’t personally find this all that compelling; even if there’s clear bias against trans youth in the methodology and the focus appears to be more about what bigots think than what benefits service users, ultimately The Cass Review didn’t find the smoking gun the transphobes wanted and we won, right?

Well we would have if not for what is recommended by The Cass Review. The 32 recommendations, informed by the highly conservative evidence base, look to impose further restrictions and control on trans lives — and not just the lives of trans youth with the scope of these recommendations including 25 year olds.

Given that we know The Cass Review has been majorly influenced by anti-trans activists with ties to conversion therapy efforts, it’s probably worth looking at some of the recommendations and how they relate back to what transphobes are doing to organise against trans liberation.

The first recommendation in The Cass Review worth pointing out is recommendation 2: “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. The framework should be kept under review and evolve to reflect emerging evidence.”

Transphobes have long been trying to argue that many young trans mascs aren’t really transgender and are instead simply gender confused autistic girls being taken advantage of by big pharma. Groups like Transgender Trend, who Cass follows on social media, have produced multiple documents along these lines.

So whereas I would accept and fully support screening for neurodivergence being part of the diagnostic process for trans youth under normal circumstances; these aren’t necessarily normal circumstances. Things like this should be watched with caution as it would be all too easy for this to become a barrier for neurodivergent trans youth in accessing care.

Recommendation 5: “NHS England, working with DHSC should direct the gender clinics to participate in the data linkage study within the lifetime of the current statutory instrument. NHS England’s Research Oversight Board should take responsibility for interpreting the findings of the research.” Is also worth of a bit of side-eye.

It has already made the mainstream anti-trans press who ran with fearmongering headlines concerned about “the fate” of 9,000 trans people who began transition in youth services but have been moved to adult services due to age. The Cass Review was unable to get data from adult services on account of the human right to privacy and the fact that our medical data is *our* medical data; not yours.

Trans people shouldn’t be forced to participate in research. Especially not to satiate bigot whinging. If research is being done then it should be something trans people of all age groups are able to opt into or out of.

Recommendation 6 is a long one and has a couple of addendums. “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. This should look at the characteristics, interventions and outcomes of every young person presenting to the NHS gender services.”

As we know, the intention for this puberty blocker trial is to hold treatment hostage for participation in the trial. This is horrific and completely unethical. But it gets worse in the first addendum;

“• The puberty blocker trial should be part of a programme of research which also evaluates outcomes of psychosocial interventions and masculinising/ feminising hormones.”

I imagine following the same basis as above but also further worthy of caution as anti-trans efforts have previously attempted to argue that HRT doesn’t significantly improve mental health and is therefore not good treatment for transgender people. These arguments generally ignore (ever increasing) transphobia as a factor in a trans person’s mental health.

Recommendation 7: “Long-standing gender incongruence should be an essential pre-requisite for medical treatment but is only one aspect of deciding whether a medical pathway is the right option for an individual.” Essentially functions as a “get-out clause” for Doctors to avoid prescribing even when a patient has demonstrated gender incongruence for a long time.

Recommendation 8: “NHS England should review the policy on masculinising/feminising hormones. The option to provide masculinising/feminising hormones from age 16 is available, but the Review would recommend extreme caution. There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18”

This is just cruelty. If we assume that the patient is one of the lucky few to have been offered PBs under Cass’ recommendations then that means at 18 they will be largely pre-pubescent amongst near fully-grown adults. Trans youth already express concern and anxiety about ‘falling behing their peers’ in terms of physical development when allowed to medically transition at 16. The idea that they should have to wait until 18 is what should have the clear clinical rationale — not the other way around.

Recommendation 9: “Every case considered for medical treatment should be discussed at a national Multi Disciplinary Team (MDT) hosted by the National Provider Collaborative replacing the Multi Professional Review Group (MPRG).”

The wording of this is unclear but on the assumption that they mean before treatment is allowed; then this is just another waitlist in the making. Elsehwere in Cass we are told there are nearly 1,000 patients currently being referred to endocrinology which represents a 1,000 patient backlog on day 1 should this be implemented.

To clear this within a year the MDT would have to ‘discuss’ 3 patients per day, every day, no weekends off, while taking no new patients.

Recommendation 10: “All children should be offered fertility counselling and preservation prior to going onto a medical pathway.” A short one but still worth mentioning is that the anti-trans view is that any treatment will make you permanently infertile and it has to be stated that this is not true.

In fact trans femmes like myself are warned not to assume we’re unable to get someone pregnant whereas trans mascs are pretty well established as being able to get pregnant at this point. Yes, puberty blockers and/or hormones can impact this — but it isn’t a hard and fast rule and in many cases simply ceasing to take blockers/hormones leads to the recovery of reproductive ability.

Recommendation 13: “To increase the available workforce and maintain a broader clinical lens, joint contracts should be utilised to support staff to work across the network and across different services”. The anti-trans view is that we are already spending too much money on healthcare for trans people and they regularly accuse orgs of big pharma conspiracy theories.

In adult trans services massive backlogs and years long waitlists began, in part, due to a lack of funding. In short; to do the kind of gatekeeping both Cass and adult gender clinics wants costs a lot of time, money and effort; none of which the NHS super want to spend on less than 1% of the population.

Especially when, as trans people keep pointing out, they don’t have to. Informed consent models of treatment are significantly cheaper to operate and much fairer to the patient who ceases to be viewed as a problem to be solved and starts to be viewed as a person with autonomy.

Other recommendations I haven’t mentioned also talk about creating organisations and review teams and all of this other stuff and yeah no its just wishful thinking. They don’t have the money for it and even if they did they wouldn’t want to spend all of it on us anyway. The services will be a shadow of what Cass is recommending and even the best version of her reommendations should be approached with a cautious eye.

Recommendation 16: “The National Provider Collaborative should coordinate development of evidence-based information and resources for young people, parents and carers. Consideration should be given as to whether this should be a centrally hosted NHS online resource.” The NHS already received massive backlash for repeatedly removing trans supportive documents from its websites after complaints from transphobes.

Recommendation 22: “Within each regional network, a separate pathway should be established for pre-pubertal children and their families. Providers should ensure that pre-pubertal children and their parents/carers are prioritised for early discussion with a professional with relevant experience.”

Cass states that her evidence base “suggests children who present with gender incongruence at a young age are most likely to desist before puberty” and so essentially this is just yet another recommended ‘wait and see’ service. It’s billed as attempting to “keep options open and flexible” by which they generally mean “we hope you don’t transition”.

Recommendation 23: “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.”

There has been talk elsewhere about how this service would primarily function to deny transition to those up to the age of 25 years old. So its definitely worthy of approaching with caution. However the idea of a follow-through service in general is not necessarily a bad one in my opinion.

I have written about trans youth who died by suicide after being moved from youth services to adult services and realising that their wait to be treated would begin again. This is bad and does need to be fixed. But according to Cass’ own data a total of 9,000 patients are estimated to have moved from youth to adult services. That’s nearly double the number of patients on the waitlist for first appointments at one of the smallest adult services.

More wait lists will never solve the problems caused by waitlists.

Recommendation 24: “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.”

This is just worth including because its funny. Trans people keep telling the NHS what we need and what we want and the NHS just keeps refusing and saying they don’t know how to fix it.

Recommendation 25: “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.” Absolutely! And giving them the option to find another service to go to is completely necessary too, I don’t disagree.

I just also don’t think its possible without the NHS giving up some of it’s control. I can’t stress enough just how stretched thin the NHS is over trans provisions already (as a direct result of working to maintain its control over trans lives above patient safety and desires). Now we’re expecting them to have multiple options for the tiny minority of trans people who detransition alongside everything else Cass recommended? It’s a joke.

Recommendation 26: “The Department of Health and Social Care and NHS England should consider the implications of private healthcare on any future requests to the NHS for treatment, monitoring and/or involvement in research. This needs to be clearly communicated to patients and private providers.”

If this were simply about participation in research I’d have a lot less to say. Controlling variables is important when doing research. But it isn’t, it very clearly states that Cass is recommending use of private healthcare impact future requests for NHS treatment and monitoring. Essentially offering to punish trans people for the failure of the NHS to provide healthcare in a timely manner.

If the NHS is functioning so badly for us that our only other option is to spend ludicrous sums of money accessing private healthcare or DIY solutions; that isn’t on us. We shouldn’t be punished for trying to survive.

Recommendation 27: “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.”

Again targeting private and DIY options that trans people have to resort to due to the NHS’ failure to provide. These doors would shut on their own if the NHS were accessible to trans people; oddly enough we don’t want to buy hormones from websites based out of Vanuatu if we can help it.

Instead of recommending ways of supporting trans people into not needing these options, Cass recommends targeting the only lifelines we have. This is not good healthcare.

Recommendation 28: “The NHS and Department of Health and Social Care needs to review the process and circumstances of changing NHS numbers and find solutions to address the clinical and research implications.” This is just Cass on her spyware shit again.

In short; new NHS numbers were a work around to computer systems that didn’t allow health care professionals to change patient gender markers. Instead we get given a new number and sent on our merry way. I don’t disagree this isn’t necessarily the best method of doing it and absolutely does make things difficult when trying to include us in research.

I just don’t think the primary reason for changing this should be to force us into research more easily. It should just be because trans people exist and our computer systems should reflect that by allowing you to easily change a gender marker on the occasion.

The remaining few recommendations (29–32) are about creating more orgs and milestones and audit processes and what not. All of which we’ve established costs time, money and effort that the NHS has never once shown an inclination on spending on our communities.

Overall the recommendations do not appear to work to benefit the patient but instead work to benefit researchers. Their goals are not to provide timely healthcare, cut down on wait lists, reduce anxieties and improve mental health amongst transgender patients; but rather to organise us into a fashion which makes doing data science easier for them.

If it weren’t for the clear influence of transphobic groups through The Cass Report I would go as far to argue that the rollbacks on trans youth healthcare were incidental. Her single-minded focus here is on generating research and data to be used to either justify or, more likely, oppose trans healthcare.

For Cass and these recommendations; the lives that will be harmed and the children that will die as a result of them are not a bad thing. Cass might even say that its for the greater good; just think of the data that we will generate!

That’s all trans people are throughout The Cass Review. An opportunity to generate data; not human, not suffering, not struggling, not people just wanting to get on with our lives, not people who just want to have our bodily autonomy.

None of that. We are nothing but numbers that, by design, will never show the benefits of transition or be used to improve services — they will only ever show a need for caution and further control over trans lives.

But at least we are making incredible art about it.