Should the Cass Review Have Gone Further?
There were thirty-two recommendations made by Dr Hilary Cass in her 388 page review. That’s a lot, but were they emphatic enough? And should there have been others?
There is no doubt in my mind that the Cass Review could have gone further in its demolition of opposite-sex imitation medicine (I have written previously on this):
For a start, there is the clear ethical position “First Do No Harm” which seemed not to play as big a role in the four years of study as perhaps it might have. And then there is the precautionary principle – if we don’t know whether this patient will benefit why should we go ahead with a harmful procedure?
There is enough evidence, and also evidence of lack of evidence, to point to a complete moratorium on opposite sex imitation medicine being not only justified, but an urgent necessity.
So why was this defensible safeguarding position not taken? Why was this opportunity missed? Why will young people continue to be maimed and sterilised on the NHS without any clinical justification?
One thing that constrained the Cass Review was its terms of reference. It was not within the remit of the review for it to take a position on adult opposite-sex imitation. Indeed, there was a challenge to get the review to accommodate adolescents all the way up to age 25, and the report is to be commended for managing to address this cohort, something I advocated for. 17-25 year-olds are the largest group at risk of ideological iatrogenic harm from gender identity ideology. While the medical evidence is clear that the administration of wrong sex hormones is unconvincing (a NICE review classified the research that sustains this treatment it as low quality and low probability), the Cass Review was not tasked with taking a view outside its terms of reference, so Recommendation #8 reads:
“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.”
Importantly, then, there is to be a review of wrong-sex hormones. The review could not take a position itself, so it delegated the task to a subsequent review. Let us all hope this gets underway with the sense of urgency that current damage being done demands. However, 16-18 year-olds were within the terms of reference, so we must ask why the Review recommends ‘extreme caution’ rather than a complete prohibition. Demanding a ‘clear clinical rationale’ should in any case (assuming an absence of ideology) result in no wrong-sex hormones being prescribed to this cohort. In which case, has the desired outcome been achieved by applying three Band-Aids (the review, the call for caution, the requirement for clinical rationale) instead of the bandage that would have been ideal? Well, maybe, but that metaphor has further value if one imagines the efficacy of such bodge jobs.
There are other recommendations where a mealy-mouthed paragraph stands in the stead of something clearer and unequivocal. There is a theme.
The Cass Review, then, seems to have been compiled as if it were a major trauma unit equipped only with sticking plasters. It is my view that this was deliberate, rather than necessary. And the reason?
Politics.
It was a stated objective of the Cass Review from the outset to seek consensus. However, anyone familiar with the concept of binary will soon realise that there is no consensus to be had. And that is why the review was a fudge in the Great British tradition of political fudges. This was a review straight out of the Theresa May playbook, something that tries to please everybody and succeeds in only pleasing the gullible and otherwise soft-headed. It was not entirely a project to kick the can down the road. Already, we have seen the Sandyford Clinic in Scotland halt prescription of puberty blockers. Yippee doo. There are less than 100 children on puberty blockers for reasons of gender (there should be zero of course), yet thousands of adolescents on wrong-sex hormones, both via the NHS and via private, cowboy outfits.
The review succeeded in setting in motion the inevitable end of opposite-sex imitation medicine. Yet it was not nearly as emphatic as those of us with skin in the game needed it to be. We needed action when the scandal emerged. Such opportunities came when Sue Evans blew the whistle, when Transgender Trend was established, when parents including those from Our Duty, tried to hold the Tavistock board to account. There really must be an inquiry into the failure of governance at the Tavistock. The children at risk needed decisive and urgent action as soon as the scandal was identified, they still do.
Whatever the Cass Review said, it was only to be expected that advocates of opposite-sex imitation medicine would object to it. It was inevitable that the report would bring the most rabid promoters of gender identity ideology and its associated medical interventions, out of their basements, frothing at the mouth all blue hair and spluttering nonsense from the same hymn sheet (“98% of studies were ignored!”). This was to be expected, regardless of how hard or soft the Review reported its findings. However, in pitching the report so as to minimise the total uproar volume, it failed (at least in the short term) the very children it was established to protect.
The report was sufficiently short-measured to attract the support of the Labour Party. This result, considering the Labour Party was hitherto an enthusiastic promoter of child abuse, might on its own be considered to justify the unnecessary loss of children’s futures that such equivocation has guaranteed. This is especially the case when it looks likely that Labour will form the next government. Would the Labour Party have embraced the review’s findings had those findings been more emphatic, had the language in the report been more objective? Perhaps not, and then we would have had to endure at least five years of enthusiastic butchery. In any war, and this is one, a general must weigh up the lives he is willing to sacrifice against the lives that might be saved.
We have no way of knowing whether there was political input into the review. Were there ‘Special Advisers’ signalling what Wes Streeting (Shadow Secretary of State for Health) would find acceptable or beyond the pale?
And then there was the half-hearted welcome from Stonewall. Was that a target for the Cass Review, or a pleasant surprise? Frankly, we should not care.
As I predicted at its establishment, the Cass Review was a sop, and it was the political long grass. However, is that because it had to be?
If it had been the best it could be from an objective perspective, would it then have failed to be well-received by those open to persuasion?
And while it was inadequate and incomplete from an evidence-based medicine perspective, and from a safeguarding perspective, it did contain some crucially important and very welcome positive developments. Possibly the most important of which is the review into adult services.
In the UK 70% of those in adult services are under 25. Moreover, the largest age group at referral is the 17 year-old passed up from child services. In another, very welcome move, there will be follow-on services for 17-25 year-olds currently in the child system. Whether these adolescent services will be available for new referrals 17-25 is not known, but they should be.
When you are haggling over the purchase of a car, and the deal is done, and everyone walks away with smiles on their faces. The seller might be thinking “could I have got more for it?”, the buyer might be thinking “could I have paid less?”. Such thoughts are, of course, moot once the deal is done, but they are, I am sure, commonplace. In the following weeks, the buyer realises the brakes need replacing, as does the cambelt and clutch, and the tyres, too. Well, what then?
Perhaps the most important recommendation of the Review as regards the framework for dealing with children presenting with transgender ideation is in Recommendation #2 which says “The framework should be kept under review and evolve to reflect emerging evidence.” One would like to think that the missing objectivity can find its way into medical practice via this route. However, that does rely upon an NHS free from ideological influence. And removal of the ideologues from the NHS was, if anything, the biggest missing recommendation.