Reviewing the Cass Review

A Tale of Two Ideologies

When the Final Report of the Cass Review came out on 10 April 2024 I set out to reading it reasonably optimistically. The Interim Report published in February 2022 had contained convincing language and indicated a certain strength of resolve to stick to evidence-based medicine and avoid, as much as possible, politicised or biased language. My original thrust, in reading the Report, was to assess its value in building a wider human rights, women rights and child protection arguments against gender ideology. I ended up doing a close critical reading of it and being somewhat disturbed by my findings and, even more, by the completely uncritical acceptance of the Report in GC circles.

In fact, publication of the Report engendered three types of reaction:

1. Unqualified rejection, either by deranged accounts on social media, about which no more needs to be said, or by academics who really should know better but are too far down the rabbit hole of gender ideology to find their way out again;

2. Unqualified acceptance by ‘gender critical’ (GC) organisations and individuals, singing the praises of the Report for bringing back sanity, evidence-based medicine, safeguarding and proper four-seasons weather (I may have made the last one up);

3. Qualified acceptance to a greater or smaller level. As an example, the Stonewall Statement is remarkably even-handed, but even the Mermaids Statement is not an unqualified rejection of the Cass Review findings.

I never thought the day would come when I would commend Stonewall’s reaction to anything, but in good conscience I cannot accept completely and without qualifications the findings of the Report. Before explaining why, let me just add mine is not a political position and I am not taking aim at the effects of the Report, which surely constrain organisations which have a more political or activist role and therefore are not free to provide a critical reading. In fact each side is cherry-picking the wording that furthers their political cause. I would add though that it is slim pickings indeed for the GC side. Even on a topic as important and yet not central to the Review as social transition, the language in the Interim Report (‘social transition is not a neutral act’) was a lot more helpful and clear than the ultimately useless chapter on social transition in the Final Report, where binders are mentioned without any comment on their deleterious health effects on girls and young women.

I have two distinct sets of reservations about the Report: the first is procedural and the second substantive. As for the procedural, there are two main areas: the first is the decision made to exclude from the purview of the Review any problematicisation and any investigation of the meaning of gender dysphoria and all the accompanying language, as exemplified by the opening of the Report:

Imagine a review on the treatment of cancer that decided not to explore the meaning of cancer as a dignosis. In fact, the Report, though it is a Report reviewing the medical care of children with a diagnosis of gender dysphoria, seems never to investigate whether being ‘trans’ is in any way an evidence-based condition, or whether there is a way to meaningfully distinguish between ‘trans children’, whatever that means, and children affected by gender dysphoria who can, according to Dr Cass, benefit from medical care, including puberty blockers, cross-sex hormones and eventually, surgery.

Relatedly, the second procedural reservation is on the language adopted in the Final Report. Whenever I expressed my reservations on social media about the language I was immediately reprimended by GC people about Dr Cass needing to use ‘neutral language’. I am used by now to being scolded by GC people for expressing my ideas so I was not overly concerned by the patronising tone. But my point is precisely the opposite. Dr Cass is NOT using neutral, evidence-based language. She is adopting almost wholesale the ideological language of gender identity ideology. This is evident in three distinct instances:

1. The section on ‘Language’ at the beginning of the Report, where Dr Cass indicates that she is using ‘respectful’ language that ‘acknowledge[s] diversity’ but not directly indicating that she is adopting only scientifically accurate language (the very weak ‘that accurately describes the complexity of what we are trying to articulate’ sounds like something a post-graduate student would write in their dissertation);

2. The body of the text, where non-scientific language is adopted with abandon;

3. The Glossary at the end, which does not contain any of the non-scientific language adopted in the body of the text which is crying for a definition.

As for the first, the most disturbing use of the language is in the distinction the Report makes between child and young person. Here is the text:

Let’s for now put to the side the fact that the creation of the ‘young people’ category for what the law considers children is a creation of gender identity ideologists, and that some girls enter puberty at 10 years old (I did). I was a child, not ‘young people’. But even more disturbingly, the Report recommends the following:

My objection to fertility counselling and preservation goes to substantive reservations I have on the Report; the point here is that, as a matter of language, the Report is suggesting that pre-pubertal children should be offered fertility preservation. We may be talking about 9-year-old girls here, or 11-year-old boys. This is what Mermaids recommends. But at least they talk of young people.

Biased and political language that has no scientific basis or objective evidence is used liberally in the text. Here are some examples:

Here Dr Cass is calling men who believe they are women ‘trans females’. While I object to calling them trans women, females is even more clearly restricted to individuals who are of the female sex. This is ideological language, not neutral and not evidence-based.

Binary and non-binary gender identities are mentioned throughout the Report, as if they were real, objectively observable conditions, as opposed to concepts embedded into a system of belief. Also note ‘birth-registered gender’. The Report uses birth-registered sex often (this is language for which gender ideologists such as Tim Hopkins have expressed a preference, see this thread) but it also often uses gender and sex interchangeably, while gender and sex are not interchangeable, because, while gender can be a polite substitute for sex, sex cannot be a substitute for gender. In any event, scientists should use accurate language, not polite euphemisms.

Gender diverse and cisgender are meaningless words scientifically. Noticeably, GC women who insist cis and cisgender are offensive are not bothered by Dr Cass reducing them to a subset of their own sex class.

In the Glossary none of these terms is defined or explained, giving the impression that they are simply the scientifically accurate terms to use. They are, as I hope GC people agree, not so. It is not that I am offended by this language, I seldom take offence at language. The point is that adopting this language acritically means accepting the underlying ideology acritically. And if GC people think this is a concession worth making, they are still underestimating how dangerous the ideology they are fighting is. In an ideological battle, or in a battle with a totalitarian ideology, you never concede on language.

On to the substantive reservations. A disclaimer to start: I am not a medical doctor and I am not a scientist, but I am not an idiot either, so I know that sex is binary and immutable and that plastic surgery does not change sex. I also know that ‘passing’ is not a medical remedy and that, if the satisfaction level for a medical transition is assessed by how well someone passes, it simply means we are made responsible for the efficacy of a mutilating medical treatment.

Also, I am not reviewing how the evidence was collected, which studies were included and which were excluded. There is plenty of commentary on this already. I will only note that the fact itself that NHS bodies refused to cooperate with the Review should have resulted either in a political intervention to force the NHS to cooperate, or the interruption of the Review and an immediate stop to any treatment, pending the resumption of the Review under different and stricter remit. Neither of this happened, and it is frankly surprising that Dr Cass felt able to reach any conclusions while being prevented from doing her job properly.

I will therefore restrict myself to expressing the most robust reservations to the adoption, by the Report, of discredited or dubious claims, which we are used to read in ‘medical’ literature as the one produced by the World Professional Association for Transgender Health (WPATH).

An especially egregious claim is that fetuses do not have a sex until affected by hormones produced during pregnancy.

Another claim made in the Report is that cross sex hormones induce the opposite sex puberty. Appallingly, Dr Cass refers to this as the ‘desired gender puberty’.

This pseudo-scientific language is straight out the WPATH Standards of Care 8 Guidelines:

For the avoidance of doubt, inducing the development of some secondary sex characteristics of the opposite sex via cross-sex hormones is not the same as experiencing a puberty. No girl will start producing sperm and no boy will start releasing eggs and menstruating, which is what male and female puberty are about. You can make a middle age man develop some breasts by giving him aestrogen. He is not experiencing a female puberty.

Disseminating such pseudo-scientific drivel undermines the credibility of the Report and, more dangerously, prevents a proper scientific debate. It is bad enough to concede on language, but to concede on fundamentals such as the sex of fetuses or the meaning of puberty is unconscionable.

But of course the worst effect of the Report is that it accepts that some children are trans or queer;

That some children benefit from puberty blockers and even cross sex hormones;

That surgery is an appropriate pathway, effectively sterilising adults on the basis of a mental health condition;

That ‘passing’ is an important variable in assessing the efficacy of medical transition (this is straight out the Dutch Protocol);

Given these premises, it is no surprise that Dr Cass does not recommend that puberty blockers are not to be given to children except as a temporary pause in precocious puberty, or that cross-sex hormones are never appropriate for minors.

I am not the one qualified to make a medical argument against the use of gender affirmative approach. But I am qualified to demand that a scientific report adopts only scientifically accurate language and does not espouse pseudo-scientific theories. This Report does neither.

Finally I worry that women and girls are the collateral damage of the results obtained by the Cass Review: while of course preventing the use of puberty blockers on children is a result to be commended, this victory cannot be used as a bargaining chip to be exchanged with the legitimisation of gender identity ideology. And for those who failed to notice it, gender identity ideology has already dispensed with the need to medical transition. Men are women on their say so. And the Cass Review will not be of any help in fighting self-ID laws, which are being embedded in German and US law as we speak. Indeed by recognising the legitimacy of the whole ideological baggage of gender identity, the Cass Review results may even hinder any attempt to disembed this ideology from the law.