I've been contacted by someone who took part in the Cass Review, & believes this is their quote. They wish to make clear their "words have been misinterpreted by the report" & they are "on hormones but don't plan on getting surgery & that's what that specific quote was about!" https://t.co/zD4pYwBJeW pic.twitter.com/PagFOjCpov
— TransSafetyNow (@DadTrans) May 16, 2024

How many more kids must die before the direct correlation between denial of service and death by suicide is recognised? Faux concern and ‘what about the children’ is a smokescreen for bigotry. The UK is ignoring all of the evidence that proves gender affirmative care saves lives
— Susie Green (@green_susie100) May 2, 2024

Transcript

Ashleigh Talbot: Hello everyone. And welcome to our Cass Review deep dive episode. If you’re hearing this then I can only assume you’re a glutton for punishment, because this is the second half of each of the last two episodes edited together as one, big, Cass-focused chunk of work. Featuring interviews with Doctors Cal Horton, Cora Sergeant, Natacha Kennedy and Reubs Walsh. We’ll explore some of the connections between the Cass team and people who will openly advocate for conversion therapy practises, and we’ll also have a look at what the report itself says and how that can -and already has- caused harm to young trans people, and especially those on the care pathway the report pretends to care so much about. We hope you find this useful in some way, we’ll be providing links to some of the resources we used to put all of this together and you can find a link to this in the description of this very hefty episode. So without further ado, take it away Alyx and Ashleigh in the past!

Alyx Bedwell: The Cass Report. We’ll read it so you don’t have to.

Ashleigh: We’ll read it several times, in fact.

Ashleigh Talbot: Speaking of people who are trying to stop the provision of needed healthcare, it’s time, you knew it was coming, it’s the Cass Report.

Alyx: Too many.

Ashleigh: As we’ve spoken of in the last couple of episodes, the report was published on 10 April, it’s stopped referrals to Gender Identity Clinics for all young people and it’s actually accelerated a similar review into adult services as well so thanks for that. The contents of it have been described not least by me as overreaching and the methodology has been unethical by several of the experts you’re about to hear from and of course as many of you will have seen it’s been an absolute media circus that’s followed it. The Cass Report is split into five specific parts.

Alyx: Part 1 talks about the approach the Review took and the work they undertook.

Ashleigh: Part 2, the context which explores the history of services for children and young people with gender dysphoria and highlighting the changing demographic and the rise in referrals over the last few years.

Alyx: And for Part 3, it was understanding the patient cohort and sets out what we have learnt about the characteristics of children and young people who are seeking NHS support for gender incongruence and considers what may be driving the rise in referrals and the change in the case-mix. That’s this episode.

Ashleigh: And on the next episode we’re going to be moving onto Parts 4 and 5. Part 4 is the clinical approach and clinical management which looks at what we need to do to help children and young people to thrive, basically, the purpose, expected benefits and outcomes of clinical interventions in the pathway, including the use of hormones and how to support people who have slightly more complex presentations when they arrive at a gender clinic.

Alyx: Part 5 goes over the service model and considers the gender service delivery model, workforce requirements, pathways of care into this specialist service, further development of the evidence base and how to embed continuous clinical improvement and research. This will be our throughline when we walk you through this.

Ashleigh: So now you know what you’re going to be stuck listening to for the next god knows how long and throughout this we’ll be bringing on as many trans academics as we could wrangle onto the podcast so strap in, this is going to be a long ride.

Part 1

Alyx: Oh boy and with that we jump to Part 1, the way the Cass Review approached the Review. And with that, we hand over to Cal Horton. Cal is a research fellow in Oxford Brookes’ Centre for Diversity Policy Research and Practice with a specialism in trans inclusion and Applied Trans Studies.

Cal Horton: “The Cass Review relies upon a systematic review of literature on social transition, conducted by the university of York, in partnership with Tilly Langton. Tilly Langton is a controversial former clinician at GIDS, the English children’s gender clinic that has recently been closed down. The Trans Safety Network has raised concerns about Tilly Langton’s connections with Gender Exploratory Therapy, an approach the Trans Safety Network consider to be conversion therapy. Having such an individual at the heart of the research team leading the systematic reviews has raised significant concerns.

The systematic review conducted by York took a portion of current literature on social transition. Qualitative literature, so literature that actually talked to and listened to trans children or families, was disregarded. My own peer reviewed articles on the experiences with social transition of trans children and families in the UK was not even acknowledged. Which may strike you as strange in a review that continually bemoans insufficient evidence.

The systematic review summarises its selected portion of existing literature on social transition in a way that decentres and erases critical research findings. Reading the York systematic review provides limited insight into what the existing literature actually says about social transition. By contrast, I reviewed all existing literature on social transition in a peer reviewed scoping study published at the start of this year in the leading journal for trans healthcare, which is worth a read if you want to see what the current literature actually says about social transition.”

Ashleigh: If you want a longer form explanation on this, last episode, Cal did a brilliant 35 minute monologue going into more detail. And you can also find the transcript of that linked in the description of this pod.

Alyx: So, the Cass Review brought on someone who actively pushes conversion therapy and chose studies avoiding actually talking to trans people. So with that, we spoke to Luci from our fantastic consultation team to talk more about the involvement of conversion therapists in the Cass Review.

Luci: So Tilly Langton’s involvement is quite interesting, so Tilly is working for York University under someone called Jo Taylor who is running the whole report. Tilly is the only person with experience of the gender dysphoria service or the gender identity service in the whole research team. There’s one other person with experience in young person’s care and that is Lorna Fraser, she’s fine, she works for King’s College in London in children’s palliative care so is actually a respectable person but also her involvement wasn’t as substantial as Trilby’s. Trilby is Tilly’s other name, this can be confusing and make it slightly more difficult to dig out the information about her. Sometimes she goes by Tilly, sometimes she goes by Trilby. I mean who are we, trans people, to complain about people having more than one name, I’m not going to comment. So she was working for York on the research that was commissioned by the Cass Review, that involved various different papers and is called the systematic review of research and what was done with that was, as your listeners are probably aware, they looked at all of the massive amounts of research on young people’s care in general and then through most of it out. This is something we have seen before with the NICE review so there is precedent for this and you might be like well, the thing that people are saying is oh it’s low quality research but they got to set the terms of what they defined as low, medium and high quality and the criteria that they applied is one that excluded and defined most of the research out of being looked at which is at best really bad practice. You look at that approach and you’d be like well that seems inadequate and slightly unprofessional, right, at best, that’s poor research. And as time is spent on it we’ll see in the next couple of years actual academics bring that complaint, that takes a long time because of the way that academia works. And you might be like well that looks incompetent and you might level that at the whole research team until you look at who did what and you learn that it was only Fraser and Langton who designed the selection process for the research.

So there were only two people on that team who were deciding what approach to take and what research to look at. I would be curious to hear Fraser’s thoughts on this as she seems to have no connections to any organisations, she seems to be just a professional, so it would be interesting to see what she has to say about her involvement in this process once it hits the fan academically. Langton, on the other hand, used to work for Tavistock along with many other people. Lots of child psychologists were involved in Tavistock but Langton was part of the cohort of people who left and some of whom whistleblew on the approaches that Tavistock were taking. The two names that are going to come up there a lot are Anna Hutchinson and Ana Spiliadis, I’m sorry if I’m mispronouncing those, and these people are tied together in various ways, some of which are a matter of public record so these three individuals – that is, Langton, Spiliadis and Hutchinson – went to meet with our favourite politician Kemi Badenoch in 2021 to discuss the conversion therapy bill so they are engaged consulting politicians on this process. We know that they are involved with each other, they also all work together. That’s not weird, that’s just how the industry works, but the thing that ties them all together really strongly and the thing that causes us concern is their connection through something called Explore Consultation.

This was broken I think in 2022 by Mallory Moore for Trans Safety Network and was really the thing that put us onto this person’s involvement in bad stuff and the reason for this is because Explore Consultation is a group of five people, so it’s Spiliadis, Hutchinson, remember them, and Langton along with someone called Anna Clarke and Natasha Prescott were on the list of names involved in delivering some training to some NHS professionals about how to approach people who were not sure about their gender and if you want to have the full story on this you should check out the Trans Safety Network’s article on it because it’s very substantial and very damning but there are many things wrong with this. We can see examples of them linking to out and out actually transphobic organisations. They link to like Mermaids and then they also link to like five other things all of which are just transphobic stuff including Transgender Trend so things that are “ideological”, you can’t see me doing my scare quotes there, and this is the only public connection that Langton has with these people. This organisation isn’t listed anywhere, all we have is some lecture slides and some pamphlets and documentation from this event. It seems like, this is speculation, once Langton got involved with the systematic review she’s obviously kept her head down with her involvement in any of these organisations and has kept it very quiet. There’s very little else you can find on her apart from her conversation with Badenoch and her involvement with Explore Consultation which coincided fairly early on in her involvement in the systematic review. I think it was reasonable to say that she should not have been on that systematic review. I would question Lorna Fraser’s involvement in that because she’s the person who’s responsible for releasing it, it’s her signature at the bottom of the review. I’d also question York Uni in general as to why did you hire this person who has this biased history, why did they fail to declare their involvement in this organisation. There are questions I would ask of these people. All this to say Trilby, not great.

There’s also other people who are involved in the review so along with the research there’s also Cass and the people that she spoke to. So with the Cass Review there are two formally involved bodies. There’s the Assurance Group which is a list of people and we have that list and none of them seem particularly weird, they are responsible for overseeing the Review in an organisational capacity. They’re the people whose names have to be on it to make sure it’s not just Cass but they seem to have been fairly hands off and none of them seem to be specialised in gender care one way or the other. There is no involvement of trans people anywhere in this Review. I believe that’s because it would be biased, I believe there’s something in the What The Trans article about the specifics of that but I can’t recall. Materially we know of no trans people involved in the Review so that’s what we know. So the Assurance Group, you can find the list of them in the Cass Review if you want to look it up. The other one is the Advisory Board which is different and they are also formally involved in the Cass Review and we do not know who is on that list. It’s secret for some reason, some procedural thing, that is apparently normal for reviews like this but it is also something that should be made public because of how much there is wrong with the Review. We need to know who else is on this because we only know so far one person who’s on it because she declared it as a conflict of interest in another piece of research that she published shortly before the Cass Review came out and that person is Riittakerttu Kaltiala, I’m just going to call her Kaltiala because, I’m sorry, if you’re Finnish, I’m sorry.

Alyx: Sorry to those Finnish listeners out there.

Luci: Yeah, Kaltiala is the only person who we know is involved in the advisory board and she’s no good, she’s real bad, she’s one of the architects of the Finnish system that is used in Finland now which is bad, it’s a gender exploratory approach which is, your mileage may vary as to whether or not you just want to call it conversion therapy but it is, I think that it is conversion therapy. I think there are things which come under the conversion therapy umbrella which are more extreme and it’s important to keep that in mind when discussing this but it is an attempt to challenge people’s desire to transition rather than, it sounds like oh we just want to explore it but you are exploring it, that’s the point of the whole process, it takes a long time to transition under a gender affirmative approach as well assuming it’s applied correctly by a team of people who are adequately funded and have enough time. We see the evidence of that in [inaudible] so Kaltiala along with that is involved in the Do No Harm conference which is basically the conference of transphobic stuff, they’ll platform detransitioners, bias the conversation…

Alyx: That’s the CAN-SG one that happened with the big protests outside, wasn’t it?

Luci: Yeah so you can look up that if you want, I have sat and watched some of it for my research and it’s interesting [laughs] It has a real vibe. So we believe that Kaltiala introduced Cass to someone called, where are my notes, Hunter, do I have a last name on my chart? I don’t, sorry about that.

Alyx: For those who don’t know there’s a good chart on the wall just sellotaped up right next to you, it’s a really impressive one when you look at the pictures.

Luci: Yeah, Patrick Hunter, there we go, found it. That’s the US guy, that’s the SEGM which is a transphobic group and you can follow those threads a lot and other people have done work on this to connect those people to more and more explicitly transphobic and religiously right-wing organisations that are responsible for transgender care bans in America. There is this very robust network of international conversion therapy advocates or gender exploratory advocates and then there is a more local cohort of people, some of whom might have connections to that, so for example the ‘24 conference, Anna Hutchinson, remember her, spoke at the Do No Harm conference in 2024. Hutchinson was one of the first whistleblowers at Tavistock and is also the educational lead on the interim service, the NCY PGDS. That’s a person who probably shouldn’t be involved in this but who is and it is notable that a lot of the people who are advocating for this, I’m sure they’re not short of work, but they will find a place to be in this new service that they are advocating for the construction of or involved in the architecture of. Does that amount to bias, academic or otherwise? I don’t know. Is that the motivation? I don’t know. It’s of note, though.

Ashleigh: There were also meetings with a Patrick Hunter who was, according to the Kite Trust, the “Architect of Florida’s anti-trans SB 254 bill in 2022”. But after being pressed on this, Cass’ team said they were “not aware of his wider connections and political affiliations at this time”. And claimed that he had “no influence on the content of the Cass Review’s Report”.

Alyx: And for those who missed Alyssa and Valeriya in last week’s episode we spoke to Alyssa who walked us through who this Patrick Hunter was.

Alyssa: Patrick Hunter is a Floridian paediatrician, he’s a member of the Catholic Medical Association which is a far-right advocacy group that’s opposed to transgender people and gender affirming care on specifically a religious basis. He’s also a leading member of the Society for Evidence-Based Gender Medicine, people call it SEGM a lot, which is a horrible little organisation also very publicly anti-transgender activists, they have people in their ranks like Stella O’Malley who is a self-admitted conversion therapist from Ireland, right, just a terrible place and in 2022 he was appointed to Florida’s Board of Healthcare to help them write essentially a document that would act as state-specific standards of care for treating trans patients which was named Generally Accepted Professional Medical Standards Determination on the Treatment of Gender Dysphoria.

Alyx: Is that like a Florida version of the Cass Review?

Alyssa: Yeah, more or less, same general idea is that they tweaked a lot of evidence and outright lied in some places. We’ve since discovered from discovery segments of court cases fighting the documents and the bans on healthcare but as soon as this thing, within months of this thing being put out, gender affirming care was completed banned for trans youth in the State of Florida and severely restricted for adult transgender Floridians. He was appointed to that Board of Healthcare to help write that by Florida governor Ron de Santis who is of course a gigantic stinking vile piece of shit himself.

Alyx: So that sounds quite similar to the situation that’s happened with the Cass Review and no matter if his expertise was sought out for the Cass Review, depending on how malicious you think Cass was so can you walk people through what kind of involvement this Patrick had on the Review?

Alyssa: Yeah so like I said a lot of things have been uncovered specifically during the discovery process of lawsuits to challenge these various bills and one thing we learned from Patrick Hunter’s personal emails is that in July and September of 2022 he was put in contact with Dr Cass by, and forgive me a minor tangent here, he was put in contact with Dr Cass by a woman named, and I’m going to probably butcher her name, she’s from Finland, and it’s I believe Riittakerttu Kaltiala. She’s the lead psychiatrist at a gender clinic in Tampere, Finland. She once called child services on a family for legally seeking gender affirming care for their kid outside of her guidance and that clinic has also been accused by multiple parents of essentially psychologically torturing their kids, asking them a lot of inappropriate questions about their sexual and masturbatory habits, stuff like that. So this is the woman that put Patrick Hunter in contact with Hilary Cass.

Alyx: And Cass would have been in contact with her as well.

Alyssa: Yeah, I actually have the email here if you’d like me to just read it out in full, it’s just a couple paragraphs.

Alyx: Go on then, why not.

Alyssa: So this is from Patrick Hunter to Dr Hilary Cass and he says:

[classical musical playing quietly in background during the reading of the email]

“Dr Cass, I am interested in learning more about your work in this area. I am a general paediatrician in Florida. I also have a background in bioethics. I have been appointed to the Florida Board of Medicine. The Board licences physicians and can regulate the practice of medicine. The Board is considering adopting rules regarding youth gender transition. I have been studying gender dysphoria and gender medicine since about 2015 when I first started seeing patients in my clinic. My focus has been on the history and scientific literature but in the last year I have also forged relationships with 20+ patients who have detransitioned.”

[music ends]

So [laughter] I don’t know about the validity of that 20+ patients who have detransitioned, you guys have read the Cass Report, I think it was something like they studied almost 4,000 trans youth and something like between two and ten of them detransitioned in that entire timeline.

Alyx: And even then some retransitioned as well, I take it, so not even all of them stuck.

Alyssa: Yeah and because we know that a lot of the time people detransition because of social pressure from their family and friends, because society or because they have trouble finding work, not because they’re not trans but because life has been made very difficult for them.

Alyx: Exactly, I suppose it sounds a bit suss as young people my age or less say, so in that case he was emailing back and forth with Cass, I take it?

Alyssa: Yeah so there’s two emails. The second email suggests that they met on 22 September 2022, I don’t know if they met in person or remotely but I would guess remotely based on some other stuff that they say in their emails. He provided her with documents in that email that dates when they met, what he calls “the evidence review” from McMaster University and “the McMaster report” which is the basis of the whole document banning trans healthcare in Florida.

Alyx: Yeah so that seems like quite an email chain right there. So with the contact he’s had, do you feel like he’s had a considerable influence on the Cass Review at all?

Alyssa: I do, I don’t think he had any part in writing it, any of the specifics, but very explicitly in his emails and in an email with one of his colleagues, Paul Vazquez, Vazquez makes it very clear, he says “that [the Cass Review people] are very interested in the Florida evidence review, especially the report from McMaster University”. So it’s pretty clear that the Finnish psychologist put the two of them in touch and that Cass found his horrible, riddled with lies document used to justify the outright ban of gender affirming care for trans youth in Florida relevant enough to what she was doing that she wanted to look at it. I don’t think that it’s included in the citations of the final Cass Report, I could be wrong, it’s an almost 400 page document, a lot of which is extremely…

Alyx: Crap.

Alyssa: Poorly written and boring, yeah. And even the experts on this stuff, I think a lot of them haven’t combed over every single page. I can’t attest as to whether or not those documents appear in the final Report but it’s pretty clear that they had a significant effect on the Report and I should also point out, and I have some notes here about when the Florida standards of care came out, these were so heinous that they actually prompted the closing of gender clinics at Nicklaus Children’s Hospital in Miami and Johns Hopkins All Children’s Hospital in St Petersburg. Florida, not Russia. There was a Yale review of the document, they said “we are alarmed that Florida’s healthcare agency has adopted a purportedly scientific report that so blatantly violates the basic tenets of scientific inquiry. So repeated and fundamental are the errors in the June 2 Report that it seems clear that the report is not a serious scientific analysis but rather a document crafted to serve a political agenda.”

Alyx: Oh and Cass wanted her eyes all over it. When Hilary Cass had an interview with the Kite Trust, when they were pushed on Patrick Hunter they mentioned that he had limited influence, if any, on the Cass Review. What are your thoughts on that?

Alyssa: It seems very unlikely to me. We don’t have clear evidence of them interacting more than a couple times but she very explicitly asked for those documents and he sent them to her and I would say that a lot of the final Report maps pretty cleanly to the kind of very prohibitive suggestions that they make about puberty blockers and gender affirming care in general. Most of the Cass Report’s final recommendations in general is just don’t let trans kids exist, right?

Alyx: Oh exactly, if I say any more I’d be spoiling the second part.

[laughs]

Alyssa: Yeah so I think it’s pretty likely that Patrick Hunter and his evil, terrible work in Florida had a direct influence on the Cass Report.

Ashleigh: So the picture is clear, for those of you following along on your conspiracy boards at home, we see connections drawn between people like CAN-SG speaker and member Riittakerttu Kaltiala who introduced Hilary Cass to Patrick Hunter. This is in addition to homegrown gender critical therapists like Tilly Langton and Anna Hutchinson. Just to absolutely hammer this point home, all of the trans voices have been completely excluded in favour of gender critical ones.

Alyx: And you can really see what effect it has had on the review, especially in how it selected evidence. We spoke to Cal again who had this to say about the exclusion of a lot of research.

Cal: So there’s a number of different levels. First of all there’s the research that doesn’t even get to the point of being excluded, so a lot of the qualitative literature doesn’t even get acknowledged so it’s not even excluded, it’s literally not noticed. All of my own research doesn’t get a mention as does a number of other important pieces of qualitative research. All of my research has been with trans children and families, the majority of whom are or were service users of the English and Scottish children’s gender clinics, a cohort that the Cass Review would surely – should surely be interested in but that kind of evidence, particularly qualitative evidence, hasn’t even been included or acknowledged which is frustrating in a piece of work where the authors are continually bemoaning a lack of evidence. Excluding evidence of any type seems either foolish or convenient and then the evidence that is there, it’s to do with the way the systematic evidence reviews take decisions on which data and evidence they think is most valuable underpinning the final Report or a number of they call them systematic literature reviews and the purpose of those literature reviews is to look at the existing evidence and assess its quality.

And when they say quality they’re looking at things like rigour, whether it’s representative of the actual experience of the average trans child or, sorry, the average child distressed about their gender because this is a really key point that the Cass Review doesn’t even acknowledge the existence of trans children which is rather shocking in a report that has directly and immediately impacted on children’s healthcare access. So what they do in the evidence review is they assess the quality of the existing evidence across all the systematic reviews. A vast majority of existing evidence is rated as low-quality or medium-quality but not high-quality. High or medium quality they’re looking for things like randomised control trials or formalised trials where there is a control wing, so for every child who has x intervention, there is a very similar child who has randomly been given a different intervention. There are huge ethical issues with doing that for interventions such as social transition or puberty blockers or HRT. The ethics of withholding a treatment that is known to be beneficial is very questionable and even what they define as a treatment is something I would, I think problematic because they define things like social transition as an intervention as though it is a medicalised decision.

Ashleigh: Yeah, as if it’s come from somewhere external rather than being something that the trans young person has perhaps been pushing for themselves. Like it’s magically come from outside, somehow.

Cal: Yeah and as though it could be imposed irrespective of a child’s views, as though oh someone’s got this diagnosis then they are going to be socially transitioned whether they like it or not. That’s just not the way social transition works. It also completely ignores the understanding of how active an intervention rejecting a trans child is or delaying a social transition. It’s something that some of my own research has focused very specifically on the experiences of families who have delayed a child’s social transition and to do so is a very active intervention in that child’s life and it requires daily and more than daily reintervention to continue to reject a trans child. The idea that social transition is this big, dramatic intervention that requires medical evidence to some high degree of rigour but rejection of a trans child for months or years on end doesn’t require any evidence or justification is a significant double standard and this idea of a double standard cuts across a lot of the Cass Review approach. The Cass Review will criticise the evidence base for puberty blockers or HRT as being insufficiently rigorous and then go ahead and recommend gender exploratory therapy or close psychological support or things that are sometimes not even defined what they are but certainly are not underpinned by any kind of evidence base. Across the whole discussion on evidence, the Cass Review doesn’t take the time to look at the evidence base of the potential harms of what they end up recommending. So there is a growing body of evidence of different types on the harms of conversion therapy, the harms of delayed transition, the harms of forcing trans adolescents through an incongruous puberty and these harms are documented in the literature and are very known if you know and talk to trans people or trans adolescents or trans children but the Cass Review hasn’t even looked for that data. They’ve critiqued the evidence base for all affirmative healthcare and then plucked recommendations out of the blue on what they propose to do instead.

Ashleigh: So along these double standards, it held one particular medical protocol in high regard. And used it to exclude more evidence. So we asked Cal on their thoughts on this decision.

Alyx: Could you walk us through the Dutch model and why they seem to take a shine to that?

Cal: So the Dutch were some of the early users of puberty blockers so as far back as 1988, puberty blockers were used. So there’s trans, older middle-aged people who are older than I am, and I’m early 40s, there are people older than me who had puberty blockers at the start of puberty from the Netherlands. So this is very well established and proven safe and beneficial in the Netherlands. Interestingly when the Netherlands was at the forefront of gender care for trans youth the English system for children and young people did not want to adopt the Dutch model and a lot of advocacy justifying the harms of the earlier English system was needed to get England to even consider adopting the Dutch model so hearing that people are now singing its praises are interesting. Since about 2015, healthcare providers in a lot of other countries have taken the mantle on and been more progressive and been more trans-positive and been more influenced by actually prioritising what is in the best interests of trans children and adolescents and that’s particularly clinicians and researchers in places, it’s very much focused upon the English-speaking world, and I think that’s another problem that people haven’t even looked beyond the English-speaking world because there’s a lot of interesting things and progressive things in places like South America, but in the English-speaking world the more progressive clinical practices have been in places like the United States, Canada, Australia, New Zealand. And in all four of those countries practices are affirmative and there is a lot of support from the healthcare establishment and from clinicians and healthcare providers and trans communities for a gender affirmative healthcare approach, which is different from the Dutch model which is still a bit more pathologising and a bit more focused on a lot of assessment and psychological therapy before any support for affirmative healthcare interventions. But all of those approaches from North America and Australia and New Zealand is disregarded in the Cass Review because it doesn’t fit with their model of really looking for what’s gone wrong when a child comes out as trans or an adolescent comes out as trans. And the idea that that individual might have rights, healthcare rights and might be able to access those healthcare rights without massive hurdles and massive intrusive and abusive assessments that’s outside the realms of possibility for the current people in the Cass Review and in NHS England who I think can’t imagine that kind of a trans-positive future.

Alyx: Exactly. I think when it came to the dismissing of those reviews it did even put out a whole section on just attacking WPATH, didn’t it, as well?

Cal: The section where they review healthcare guidance from other countries gives a good indication of the same techniques that you see across the wider review to discredit affirmative healthcare and someone shared that the systematic review of existing clinical healthcare guidelines, the original methodology that the Cass Review wrote up and committed to following was the methodology that explicitly says do not discount guidelines that are rated low quality. After the fact and in the latter stages of the Cass Review they changed methodology to a different methodology they adapted specifically so that low quality research methodologies could be ignored and then the process by which they prioritised rigour of clinical guidelines is very open to personal bias. They had three assessors who gave a score for each health guideline using a slightly arbitrary system that had been adapted and it just so happened that all of the guidelines that have a degree of trans community acceptance and backing and that all the guidelines that treat trans children with respect were rated as low quality because those guidelines accepted decision making based on the existing evidence. And because the Cass Review deems the existing evidence to be low quality they say you can’t make decisions based on that evidence therefore all the guidelines that make any decisions based on existing evidence are ruled themselves low quality and then they ended up with the only guidelines from Norway, Sweden and Finland, I think it was, rated high quality. And those guidelines are not considered world-class, they’re considered guidelines that give as much scope as possible for practices that are intrusive, practices that are pathologising. There’s been some really shocking example from some of those countries of some young people who’ve been within the healthcare system in those countries of some really intrusive and abusive clinical experiences and the idea that those systems are a model for the UK just doesn’t stand up to scrutiny.

Alyx: Pretty damning there.

Ashleigh: It certainly does show the philosophy of the Cass Review in quite a stark light. And to highlight it even more, this basically sums it up:

Cal Horton, from episode 104

“Being trans is seen as inherently a bad outcome. It doesn’t matter if you are a happy trans teenager, or a healthy trans adult. This is a worse outcome than being a cis adult. The Cass Review utilises HRT to justify this eugenicist bigotry. Trans people, the Cass Review argues, are more likely than cis people to require ongoing HRT – life-long medication. Therefore, the Cass Review argues, policies that can limit and reduce the number of trans people are medically speaking, morally justified. It just happens to be in the greater good to reduce the number of trans people. The Cass Review does not say this explicitly, but it is implicitly there across the Cass Review recommendations. Puberty blocker and social transition could increase the number of trans adults, and this alone is sufficient to justify restrictions. No matter the harm to trans people of denial of healthcare, of being forced through a puberty that is experienced as deeply harmful and traumatic – this harm is justified if the overall number of trans people is reduced. No matter the harms of denial of childhood social transition, of children growing up rejected and ashamed, this is justified if some children will thereby snap out of it and become cis.

In one particularly revealing paragraph the Cass Review makes clear that evidence drawn from listening to trans people will never be enough. The Cass Review writes that even if a trans boy grows into a trans man who is happy and healthy, that cannot be considered a success. His own opinion on his life cannot be counted as evidence. The Cass Review writes that because such a trans man never had the opportunity to live as a cis woman, he will never know what he has missed out on.

The Cass Review cannot find enough evidence of actual regret to argue that growing up as trans is a bad outcome. So they move to the territory of imagining a parallel world where all trans people lived as cis. Cis lives are inherently more valuable. Cis lives are inherently better.”

Alyx: This clear rejection of good ethics is also clear when the Cass Review has a clear favouring of double blind tests. In episode 103 we spoke to Cora Sargeant who had this to say about it.

Cora: I feel a little bit like the Charlie Day meme with the corkboard behind me and a load of red string across it because I read the whole Cass Review over six hours, it was just coffee and sore eyes and then I read all the systematic reviews that informed it and then I went to the hormone replacement therapy one, particularly what they call cross sex hormones but gender affirming hormone treatment, I looked at that one specifically and the psychological outcomes from that one specifically because I’m a psychologist and that’s what I’m interested in and it’s a good example of something that these systematic reviews have done, it’s a little difficult to see what they have done is the first thing, you have to look quite carefully. It’s often in the abstract where they will say only medium and high quality studies were synthesised which essentially means what they’ve done is they’ve excluded the low quality studies.

Now it’s really tricky to talk about low, medium and high quality studies in this field generally because like you say blinding is one of the things that they look at to increase the score which of course is very difficult to do when you’re talking about either puberty blockers or gender affirming hormones, I don’t know what you do with young people, just ask them not to look down for two years, I assume. You can’t really blind people to the effect of hormones. But also the studies are small-scale, generally speaking, in this field, and they’re looking for large-scale studies, which is a bizarre thing to do in a sense because it’s only a tiny population of people who are trans, it’s only 0.5% of the population at most, and of those people, the vast minority of people access hormones in adolescence. There’s this huge study in the US by Jack Turban and colleagues in 2022, 21,598 participants, huge study in the US of trans adults from the ages of 18 all the way to 65+. And of those folk, of those 21,598, they only found 119 who had received gender affirming hormones in young adolescence and only 362 who had received it in late adolescence.

So this is a tiny field and the idea that you can find large scale studies in this field, particularly when you’re talking about a field that’s marginalised and there’s not a lot of money, we’re not researchers getting huge amounts of money from grants, we’re a ragtag bunch of researchers doing our best with what we’ve got, often. So it’s a small community and it’s hard to do large-scale studies. They also marked down studies for single-site representation, so if there’s only one site that’s collected the research with one population from one site then they’ve marked it down, but of course there’s often only one clinic in the country conducting this work, prescribing hormones to puberty blockers or hormones to young people, there’s usually just the one. Like in England, just the one, I think. In lots of European countries, just the one or maybe a couple. So the idea that you can mark us down for single-site studies when there’s only one site available seems a little bit hard. So essentially what they’ve done, and they’ve also been concerned about long-term follow-up, so fundamentally what they have done is to remove those low-quality studies. So if we look at the psychology outcomes, they’ve included five studies and they’ve removed nine including that study with 21,000 participants. They removed it, they just ignored the voices of 21,000 people. And of those nine studies I read them all and we’ll go into depth on my own podcast in Classroom Psychology, we will go into depth on them because it’s super interesting, but the vast majority of them, some of them have, like de Vries and colleagues, long-term, 6-year follow-up I think, Turban and colleagues is a huge follow-up because they’re asking adults about their long-term, distant experiences, and of those nine something like seven have really positive effects for psychological outcomes, show strong positive effects.

So what these authors have done, these reviewers have done, is to restrict the medium- and high-quality studies to be the only ones that they’ve reviewed and then the Cass Review is very focused on the very high-quality studies but the actual systematic reviews that have been conducted, unfortunately that decision to exclude the low-quality evidence which is generally speaking a defensible decision when you’re talking about high-quality reviews, but this population is not your average population. It’s a small group of people, a marginalised population who don’t get access to this very often, there’s only a few sites that give you access and by excluding what is “the low-quality studies” they’ve removed their opportunity to understand the scientific consensus in this field and the WPATH systematic review that they commissioned, the countless systematic reviews across the world, the new guidance that was just released by Germany and other European countries all shows a much more affirmative model, supports a more affirmative model than Cass has been able to support, and I think fundamentally that decision to exclude low-quality work is a big part of why they’ve reached a more conservative conclusion. To my mind, we conduct and publish systematic reviews rarely as high-stakes as this but in our own systematic reviews we don’t exclude studies because of quality. We always quality assure, we must make sure that people understand the strengths and weaknesses of the studies we’re reviewing but we do not exclude studies because to suggest that 21,000 [inaudible] Turban’s, the biggest study in the world on transgender healthcare, to consider that as too low-quality for your review, it’s got to be pretty galling to Turban and colleagues, I would think.

Ashleigh: Following the release of the report, in an interview with the Kite Trust, Hilary Cass and her team stated the double blind studies would be “inappropriate” and to cap this off when we spoke to Reubs Walsh about their approach to research this is important to mention.

Reubs Walsh: I keep being astounded by her attitudes to evidence when she talks about the use of gender affirming hormones in transgender adults she specifically references it being pioneered by Magnus Hirschfeld in the first half of the 20th century. There is no mention of book burnings, there is no mention of the history and politics and context of the lack of evidence that transgender health is suffering from and I would add to that, if I can find it in my notes which I can never seem to do, “although some think the clinical approach should be based on a social justice model, the NHS works in an evidence-based way”. So she knows about Magnus Hirschfeld, maybe some muggle has convinced her that Magnus Hirschfeld’s books were never burned but the reality is that social injustice is absolutely, fundamentally part and parcel of the medical evidence we have. It’s part and parcel of how and why we know more about how to detect a heart attack in a man than a woman, in a white person than a black person, social injustices structure every facet of human society, every social process in human society and science is far from being not an example of that it is actually really a prime example of that. A lot of modern science was profoundly shaped by eugenicists, a lot of the standards of care that she harkens to as normal or usual care as applied to trans people in the mid 20th century, these were conversion practices, these were abuse and they were born of a desire to regulate the types of bodies that are allowed to exist. A book called Six Conversations We’re Afraid to Have which has not yet come out by Deborah Frances-White talks about how people can contain these contradictions.

And I really think that she’s, in the beginning she addresses the patients whose care she’s talking about, whose care she’s helping to make inaccessible, let’s be frank about it, and she seems really sincere in the care that she’s expressing but it’s still disingenuous to say to somebody I know you’ll be disappointed that I’m not going to recommend increased access to care. It’s disingenuous to say that she wants to be sure that they’re getting the best combination of treatments and that this means putting in place a research programme to look at all possible options and to work out which ones give the best results if what she means by that is a research programme you can either participate in or you don’t get care. Or she means a research programme and while they’re carrying this out everything has to stop. Birth control and abortion are, I think, really important analogies for understanding the sociopolitical dynamics of medical evidence. Birth control as an intervention spread fast and with really very little evidence, the simple reason being that adverse events from pregnancies are so much higher than adverse events from birth control that it spread through word of mouth that people believed it to be safe. This is not a randomised control trial, it’s not adequate medical evidence upon which NICE should base guidelines, however that is why birth control medications spread so quickly and with so little evidence to support them. This is also in the context, at some point in this she talks about the idea that puberty blockers have become so much more spread, fast and with relatively little evidence but unlike with birth control, when puberty blockers came on the market they had already been being used on children albeit different children with a different indication for decades. I also think that another reason why birth control spread quickly is because there was really a lot of demand for it because it gave people control over the most intimate aspects of their body and there are lots of reasons, like today in 2024 there are lots of reasons to be concerned about the long-term safety and efficacy of birth control, there’s a lot of unanswered questions, people who take birth control to prevent ovulation, there’s a lot we don’t know about the consequences of that and there is a lot of reason to think that there could be some really quite serious adverse ones. None of it compares to pregnancy.

Suicide is a pretty big adverse event. One of the studies from the Dutch clinic in adolescence, treatment as usual vs puberty blockers I think, in any case they had one patient they mentioned who committed suicide during the course of what was not a very long study who had been placed in the no treatment group for a variety of reasons and they used this, they mention the suicide and use it as an explanation for why they were right to classify that person as not suitable for care. And there is also evidence that if you look at the number of suicide attempts, people who asked for puberty blockers and were denied them in adolescence have a higher rate of suicide attempts than even people who didn’t come out until adulthood. So having a sufficiently intense awareness of let’s use gender incongruence for now, or your transness, having that awareness earlier, I don’t necessarily know that it’s actually all about gender, at that point it could be that they’ve figured out what they want and it’s about their body and it’s happening and it’s out of their control and there’s somebody who has the ability to give them back control who is refusing and that is traumatic, that is violent. It’s common sense, there’s also data to support the idea that if children ask for puberty blockers and you say no, there is a risk of suicide from that. And that’s a very serious adverse event so again, like birth control, like abortion, the alternative to not providing the treatment comes with significant adverse events, significant risk, that outweighs, I would argue anyway, the risk of providing the treatment.

So far it’s relatively rare for people to procure puberty blockers from outside of a regulated medical pathway but it will get a lot more common now than new prescriptions have been banned, it just will. That’s what’s always happened, it’s what happened with abortion, it’s what’s going to happen and as the Cass Report rightly notes, these sources of medications are incredibly unsafe. While we’re doing the analogy, how do we think people would react to a review, I mean some people would react very well to it unfortunately but a lot of people, most people, normal people would react to a review that had only cis men and specifically cis men who didn’t have any experience in obstetrics deciding about the safety of birth control and abortion because if you’re a woman or an obstetrician that makes you biased. Just to hammer home how much this analogy applies, in 14.55 she suggests that for AFABs who are distressed by menstruation, ignoring all of the other things that are distressing about wrong puberty in that direction but birth control is a viable alternative and I agree from the point of view of if there’s a clinician listening who is now going to try and figure out how best to take care of patients who are getting very distressed about menstruation, birth control is a good alternative given than puberty blockers are now not an option. But if puberty blockers are an option, I don’t think that the safety question is any different between the two.

Alyx: Their approach to research was just not great.

Reubs: Yes.

Alyx: Quite frankly a lot of the philosophy which people just kept bringing up in every single one of the interviews that being trans is a bad outcome was the negative in any kind of approach they had to research.

Ashleigh: Yeah, it seemed to be the outcome to be avoided, so if they put the person through this or that therapy and they still came out of it as trans that was a negative outcome, they had failed as far as they would be concerned.

Alyx: Yeah and in the same interview that openly states its opposition to conversion therapy, its core research philosophy is deeply rooted in the conversion therapy mindset it pretends to reject. I was really happy with that line I made there. And also later on in the website Holyrood, Hilary Cass said that there was a risk with a conversion therapy ban of a risk of criminalising clinicians.

Ashleigh: Indeed. So when she was speaking to MSPs at Holyrood she apparently had been surprised about the amount of homophobia and transphobia that there is in society and so people can be a bit scared within that community. She was asked about if we did ban conversion therapy what would the impact of that be. She said “I’m glad I’m a doctor and not a litigator because it’s a really difficult problem”. It’s not actually that difficult a problem, you just keep the roles of conversion therapist and clinician a long way from each other which is exactly what should be happening. If they’re getting close to each other then you’re doing…

Alyx: Conversion therapy.

Ashleigh: You’re doing clinicianing wrong, I feel.

Alyx: Oh exactly. Sometimes it feels like she’s trying to cover for conversion therapists in just that alone. When you’re listening into this pod and the next pod, or this supercut, keep the conversion therapy mindset that Cass has in mind when listening to points we make.

Ashleigh: Don’t put that down, we’ll come back to it later.

Alyx: Okay so just keep those bits in mind when listening in. Reubs had mentioned that gender identity clinics refused to hand over data to GIDS.

Reubs: “Attempts to improve the evidence base have been thwarted by a lack of cooperation from the adult gender service.” It’s not super clear what the motives behind that were, it’s possible that what they really mean is the adult gender service knew that they couldn’t get away with illegally handing out people’s information without their consent but alternatively it could be that they were setting out to, I mean it’s not clear what attempt to improve the evidence base they’re saying were thwarted by the adult gender services. And so if it’s other instances of which I’m aware then the motives behind that thwarting are actually being fulfilled by this review. I don’t know, maybe the motive is that they want more business essentially so by making people wait until adulthood that makes sure that all the trans people end up in the adult service. Alternatively perhaps their motive is more like for medical or ethical reasons are opposed to childhood transition and want to prevent it by blocking the evidence that would allow us to carry it out. That, obviously, requires quite a lot of cognitive dissonance. She writes that the length of the waiting list to access gender services has significant implications for this population and NHS service delivery. [sighs] Implications. Like death? All the way through this the language, subtly, but it does, reveals that Cass did kind of choose a side, actually, and I don’t think she realises that she did, but she did.

Alyx: So with that, that just shows how they did their research and with the conclusions they made with their research that leads us to Part 2.

Part 2

Ashleigh: Yes indeed. So Part 2, as we mentioned earlier on, the explanation given by Cass and the team was “Context explores the history of services for children and young people with gender dysphoria highlighting the changing demographic and the rise in referral rate.” This basically means “this is our spin on history with what gender-affirming care for trans people was”.

Alyx: And it starts off with studies from the 1980s a period of time which Cal describes in this quote quite well:

Cal: “In the 1970s and 80s the decriminalisation of homosexuality and increased movements for gay rights pushed gender clinics to be less overt in their aims. They no longer explicitly spoke of preventing homosexuality but the same proto-gay risk factors of playing with girls’ toys or being close to your mother were instead re-branded as “gender identity disorder”. Being trans was not part of the diagnosis used by gender clinics until after 2013. Before 2013 gender clinics diagnosed and problematised mainly boys for gender nonconformity. The fact that a large majority of the children being studied and probed for gender non-conformity in the 1950s to 80s ended up as cis adults is completely irrelevant to the question of how best to support trans children in 2024. Yet these same studies are relied upon for Cass’s key objection to both social transition and puberty blockers.”

Alyx: And we want to quote this part of the Cass Review just because it’s probably good to put this quote down, I was wondering if you could say this in your posh English accent…

Ashleigh: Oh sure yeah so [in a posh English accent] “[2.6] Several studies from that period suggested that in a minority, approximately 15% of prepubertal children presenting with gender incongruence, this persisted into adulthood. The majority of these children became same-sex attracted, cisgender adults.”

Alyx: And this was citing papers from a doctor called Kenneth Zucker back in 1985. I think someone who I’d recommend the audience research.

Ashleigh: Yes, Kenneth Zucker is a man we recommend you Google if you are… well it’s not for the faint of heart, let’s put it like that. Anyway, on with the quote.

[In a posh English accent, classical music playing in the background]

“These early studies were criticised on the basis that not all the children had a formal diagnosis of gender incongruence or gender dysphoria, but a review of the literature (citing a paper by Ristori & Steensma in 2016) noted that later studies also found persistence rates of 10-33% in cohorts who had met formal diagnostic criteria at initial assessment, and had longer follow-up periods. It was thought at that time that if gender dysphoria continued or intensified after puberty, it was likely that the young person would go on to have a trender...” [classical music abruptly stops] nyeeh [Ashleigh tries again, classical music resumes] “it was thought at that time that if gender dysphoria continued or intensified after puberty it was likely that the young person would go on to have a transgender identity into adulthood”.

[classical music ends]

Alyx: Now this particular part, Cal very effectively dismantles when they said in our last podcast episode:

Cal: “The 2016 literature review cited by Cass encompasses studies that aimed to eradicate homosexuality in the 1950s and 1960s, studies aiming to eradicate unmanly behaviour in the 1980s, through to studies that problematised hobbies, mannerisms and friendships in the 90s and 2000s. The majority of children in these studies were not trans. How many were trans we will never know – the study authors did not bother to ask those who they researched, and in any case, trans identity was not their primary focus. This is the foundation upon which the Cass Review bases their hypothesis that social transition or puberty blockers changes the trajectory, keeping kids as trans who might otherwise be cis.”

Alyx: So with the Steensma report which Cal talks about here, they sort of base their studies off of a very specific time period in the 40s and 50s and this extra bit of context pulls together what they were talking about.

Cal: “To answer these questions we have to understand what the purpose of a gender clinic was last century. In the 1940s being gay was criminalised and penalised across a majority of the world. Being gay was a problem. Countries and psychiatrists tried efforts to stop gayness. Literal torture and imprisonment, however, did not stop gay people from existing. The medical and psychiatric establishment recognised that they couldn’t stop gay adults from existing. But could they stop gay adults from coming into existence? Is there something that they could do in the childhoods of these people who grow up to be gay to stop this? In the establishment thinking of the 1950s, being gay was obviously and categorically a bad thing. Gay people had difficult and lonely lives. It would be better for everyone if they just stopped being gay. Eradicating gayness was clearly a moral good. The primary focus of gender clinics at this time was almost exclusively on preventing men and boys from growing up to be gay.”

Alyx: Then it went on to talk about the Dutch protocol which we covered earlier with Cal, and after this it goes on to a story of when an “affirmative model” was used, in which it prompted to heavily criticise the UK’s research methods at the time in its usual hateful pickiness over studies. So for those who are in the unknown about the situation we’ll walk you through it.

Ashleigh: So puberty blockers were in use by the Tavistock & Portman gender clinic for several years. From 2004 to 2007 a nurse named Sue Evans worked there, which will become important later, I promise. As you probably know, blockers are prescribed quite regularly to cis children experiencing precocious puberty which can kick in when the child is as young as five or six and are considered perfectly safe for use even if a child has to stay on them for a good few years. Now the use of the blockers in trans young people hinged on Gillick competence, which we’ve spoken about before, and it’s essentially informed consent for under-16s. If someone can be said to be “Gillick competent” they can meaningfully consent to their own treatment.

Enter Bell v Tavistock. As we reported on at the time in Episode 55, the aforementioned Sue Evans decided, in 2019, 12 years after she’d stopped working there, that puberty blockers were an experimental treatment that needed to be stopped and, through the magic of crowdfunding, she and a lawyer named Paul Conrath took the case all the way to the high court. Conrath was already well-known for his work combatting assisted dying and abortion rights here in the UK. He also defended the couple in Birmingham who didn’t want their child to be taught LGBTQ-inclusive Sex & Relationship Education and he also has links with the Alliance Defending Freedom and other such wholesome organisations. Nice guy, clearly.

Now as for the Bell v Tavistock case, along the way, Sue Evans was swapped out in favour of Kiera Bell, a detransitioner who comes from a strange parallel universe where people are apparently “rushed through” NHS gender services. Bell admitted that she was influenced by gender critical thinkers in her decision to detransition. The accusation of a rushed process was made to and accepted by the high court, who, in December 2020 issued their ruling that under 16s could not meaningfully consent to puberty blockers and prescriptions for them were stopped. Now this was, thankfully, later overturned on appeal.

Alyx: And also in 2020, the Cass Review was commissioned. After this bit, Cass then proceeded to pat herself on the back and talk about how they were commissioned. One reason brought up on why the Cass Review was commissioned was the exponential rise in referrals to GIDS, in which it showed a graph with a seemingly exponentially growing line. However when it was more closely examined by academics, it chose to not mention figures past 2016… because it does flatten off; something that was purposefully omitted to provide a sense of panic to the cis people reading the review.

Ashleigh: And that’s what Part 2 covers. And with that exponential rise, we go to Part 3 where it tries to blame young people and the internet for trans people existing.

Part 3

Alyx: So Part 3, this is, in majority, a sociologically-focused section of the Cass Review. And we brought an expert on this: Natacha Kennedy. And quite frankly the entire interview sums this up. So we are just going to play it here:

Ashleigh: So Natacha Kennedy, thank you for joining us.

Natacha Kennedy: Pleasure.

Alyx: So, uhm, for those of us who are not familiar: what is the diagnostic criteria, just curious?

Natacha: So, the previous diagnostic criteria 1994-2013 had “desire or insistence to be the other sex” as one of the criteria, but that was… they could have four out of five. There were other criteria there, yeah, such as preference for cross-sex roles, preference for playmates/friends of the other sex, preference for crossdressing, those sorts of things. So you could have four out of five of those. So you could theoretically have the other four and not that one. Whereas the current one it is required to have that.

Ashleigh: Yeah.

Natacha: That is a requirement. You cannot get a diagnosis of gender dysphoria unless you have that. And that is, in multiple ways that is really really important. In a sense it’s also going towards self-ID. In the end, the only people who knows whether I am trans or whatever is me. Yeah? The same with children. So it’s actually listening to them, listening to what they say.

Ashleigh: Yeah. I don’t know if this is part of the diagnostic criteria but “persistent, consistent and insistent” seems to be the thing of it; is if they keep saying it over a reasonably long time period, they’re saying the same thing quite consistently and they don’t shut up about it. Basically, they’re extremely insistent. I don’t know if that was part of the…

Natacha: Not officially part of it, but that’s a good one to look for. Insistence is what they talk about.

Alyx: You said Cass had a preference for the older spec, for the newer spec, and could have used that sort of criteria to suit their narrative more?

Natacha: Yeah, they didn’t even mention, at least I couldn’t see when I looked, it didn’t mention the new 2013 criteria. They seemed to set up a sort of duality between 20th century and early 21st century. So they kind of, they made the change; there was some sort of difference went on around 2000 which actually isn’t borne out. But they completely ignored the new diagnostic criteria. What they did talk about under the previous one was that they noticed that there was greater and lesser intensity of gender dysphoria. They got this word “intensity”, there’s nothing in there to judge intensity but they used it. And obviously the children with the more intense gender dysphoria were the ones least likely to “desist”, in inverted commas. Now I think, actually, that “intensity” argument is cis and trans. And the intensity is about the desire or insistence to be the other sex. So I think there… it’s kind of tacitly seeping into the older one anyway. And how they couldn’t recognise that in the new diagnostic criteria I don’t know.

Alyx: So on the subject of the societal norms it seems to push with cisnorma… cisgender-normative… cis supremacy, we’ll go with that. The Cass Review seemed to constantly bring up that it’s “society and not biology that causes trans people” according to the Cass Review. What are your thoughts on when it brought that up in the Review?

Natacha: Well, it’s over-simplistic. I mean I think it’s society not biology that causes transphobia.

Alyx: Mmm.

Natacha: I think we can pretty much agree on that.

Alyx: Yup.

Natacha: And that includes cis supremacy, cisgenderism, cisnormativity – all of that. To do it an either/or way like that is way, way, way to over-simplify things. Being trans is a normal part of being human and it has been that way since ever. I’m not an archaeologist, but archaeologists have said that there’s evidence going back 9,000 years for trans people. 9,000 years ago you could walk from Northern Europe to England, and you would have had to have walked because they didn’t have wheels. The wheel hadn’t been invented, at least not strong enough and light enough to go long distances. So that’s how long we’ve been around. I suspect there are elements of transness in lots of people but they’re not necessarily brought out, that society has some influence. But the influences are miniscule and you cannot control for them. A tiny, tiny thing can make an enormous amount of difference between people’s lives and people’s experiences and people’s understandings. So, I don’t think you can legislate either way. And I suspect there are different reasons anyway, and it actually, to be perfectly honest, it doesn’t matter. We exist. We have always existed. Therefore it doesn’t matter why we exist. And, you know, nobody worries about why cis people exist. And actually people have stopped worrying about whether gay, lesbian and bi people exist. I mean, yes, you do get people trying to find gay genes, don’t you? But people generally think they’re a bit weird.

[laughter]

Ashleigh: Yeah, I remember that was a thing in the 90s? Where, more than one tabloid published “oh once we find the gay gene we can look for it in foetuses and then we can perform abortions”, and just kind of leaving the whole “this will eliminate all gay people” unsaid, but that’s very definitely what it is.

Natacha: Yeah.

Ashleigh: I’ve seen it on a mug, on a t-shirt about how “homosexual acts are observed in thousands of species but only one has homophobia” and there are a lot of fish and frog and other animal species that change sex within certain environments so to say “oh you’re unnatural”… eff off. [laughter] Sorry, that was me having a rant more than anything else, because it’s just so facile, the argument that’s being made, and it’s eliminationist. And I think that’s where the Cass Review, and certainly some of the people who’ve been involved in it, I think that’s been their standpoint all along.

Natacha: Eugenicist, in the end. And that is scary. It is also, I mean, ethically, there is a number of failings in my opinion in Cass. But one of the worst is what’s called “epistemological violence”, where you take the data and your interpretation of that data pushes the worst possible scenario, the worst possible interpretation. Particularly for a minority group, or a marginalised group. And I think that is one of the things that the Cass Review is guilty of. It’s epistemologically violent, but it is also, there’s another one, just to get people confused, testimonial epistemic injustice is one of the ones where basically your opinion or experience or point of view is excluded because of who you are.

Ashleigh and Alyx: Mmm.

Natacha: I think both of those are big, big, big ethical failures of the whole thing.

Ashleigh: Should we talk about the Report’s suggestions about different toys, and about how that seems to be a completely biological thing?

Natacha: Biological toys? Well I remember a couple of GCs a couple months ago they were talking about using people’s “biological names”. So, I mean, I’ve got a…

Ashleigh: “I’m going to call you X!”

[laughter]

Natacha: I have a friend in Sweden called Mandy, yeah, he’s a real car enthusiast. He collects American cars, like Cadillacs and stuff like that, and fixes them and repairs them and stuff like that and he’s called Mandy. There’s also a Tibetan-Chinese singer who’s really really popular in Japan, sings in Japanese, called Alan, and she’s a girl. So, “biological names”. Biological toys just seems like an extension to that. I can remember me and my sister used to play with the same toys and my brother who’s cis used to play with the same toys. There was nothing biological about it.

Ashleigh: Yeah, it’s not like those things are decided in utero you know? To suggest you come out of your parent with a specific preference for doll houses or Tonka trucks kind of thing. That’s all social, that’s put on to children who are ruthlessly gendered from the day you’re born. And the colours you’re allowed to like and wear, and when you get to school it decides what sports you play…

Alyx: Those digger toys are in my DNA.

[laughter]

Ashleigh: Yeah, clearly. So there does seem to be some blame in the Report suggesting that being trans is actually more predominant in younger generations…and making it sound a little bit like a “trend” so what are your thoughts on that?

Natacha: Without being impolite, I think… I mean I was a trans child. I knew I was a girl when I was about four or five. But in those days there was no recognition of it, there was no… it wasn’t even until I was about 16 or 17 that I think that I heard a “trans” word. So, it’s just like the left-handed graph, isn’t it? Because being left-handed became more acceptable in the first half of the last century. People, I think it was about 11-12% of people, became left-handed didn’t they? Now, that may have also been due to the fact that we had two world wars and forcing someone who is left-handed to shoot a gun right-handed actually isn’t going to help protect your platoon or whatever it is. So, there may have been a social reason for that acceptance as well.

If you look at Japan, Japan has still got about two percent of the population are left-handed. That’s because there is still a cultural prohibition. People who are left-handed are taught, forced almost, to write right-handed. I think it’s starting to change but it’s not fully there, so it seems to me it’s entirely cultural. And I was talking about Enheduanna, the priestess in Ur, in what’s now Iraq in 4,300 years ago, 43 centuries ago, writing a poem which talked about trans people. We’ve always been around, it’s just that at different times there have been different cultural prohibitions on trans people. Now I suspect that increased with the Renaissance. The Renaissance was when the physical as a basis of culture became more dominant over the psychic or spiritual. I don’t know if you’ve even been to Venice or Florence but if you go to Venice all the houses, all the buildings, are all higgledy-piggledy and there’s little alleys to go through to go everywhere. It’s just grown like that. Florence, all the buildings are in an exact straight line. Florence is where the Renaissance happened, the physical became much more important as a sort of tacit under-pinning of the culture, and so that made it harder for people to come out as trans. And people still did, but it was harder. And that has kind of carried on until more recently and I think quite probably two things: one the internet made a difference…

Ashleigh: Yesss, it certainly did for me!

Natacha: Yeah, and also it wouldn’t have made a difference on its own, I don’t think, but because people are starting to come out with new vocabulary like “trans”, “transgender”, things like that because the internet, especially initially, was very much a text-based, it still is, really, a text-based medium. If you didn’t have those words it wouldn’t have been much use. So those two things coincided and enabled people to come out. So the idea that it’s a “trend” is ridiculous. You know I can remember a couple years ago suddenly everyone was wearing green. A whole load of students came into a lecture once and I thought it was St Patrick’s Day.

[laughter]

Natacha: You know, it was about a couple of years maximum, wasn’t it so trends don’t last that long.

Ashleigh: Yes, so now we have to do Part Two of that thing we promised you we were doing so let’s get on with it, shall we?

Alyx: Yes so to start off with this meat we’re going to have to issue a content warning. There will be lots of talk of medical treatments and suicide in this so just to let you know if you don’t wish to proceed further.

So who wants to bring up Bon Jovi?

Ashleigh: I’ll do that. So break out the Bon Jovi because we are halfway there.

[very short clip of Bon Jovi’s Livin’ on a Prayer]

We’re on the second half of our Cass Review talk and this time we only have two parts left of the actual Review to talk about and then a third part which is going to be us discussing the fallout.

Alyx: I don’t ever want to look at this fucking report.

Both: Ever again.

Ashleigh: Yeah, I agree, absolutely the same because for the last month and a bit now it has just been all Cass Review all the time in What The Trans towers so hopefully we can just kick this one out the door, put it behind us and start thinking about something else.

Alyx: Pages of Cass plastered on the office walls, you know.

Ashleigh: Absolutely and I haven’t even engaged with the election stuff yet because there’s about to be an election, as we record this it’s been announced, because I’ve been too busy thinking I’m just going to stick a massive pin in that and come back to it when I have got the emotional bandwidth to be able to cope with it once we’ve got this fucking Cass Review thing done.

Alyx: Oh exactly it’s like once we got the bump out the way it’s somewhat smooth sailing.

Part 4

Ashleigh: Yes indeed. Let’s crack on, shall we, with Part 4. So Part 4 is:

[classical music playing in background]

“Clinical approach and clinical management looks at what we need to do to help children and young people to thrive: the purpose, expected benefits and outcomes of clinical interventions in the pathway, including the use of hormones and how to support complex presentations.”

Alyx: And for the one after that we’re going to be looking at Part 5, which is:

“Service model considers the gender service delivery model, workforce requirements, pathways of care into this specialist service, further development of the evidence base and how to embed continuous clinical improvement and Research.”

[classical music ends]

So let’s jump right into Part 4.

Ashleigh: Part 4 essentially goes over what care young trans people will get and a lot of this is highlighted in the Recommendations. So we spoke to people who worked in caring for young trans people in the NHS and their insights on this shed some light on what was recommended.

Alyx: And just to start with, we were already told that Cass lied to GIDS staff, assuring them that GIDs would not be shut down, it would just be changing how some things would be run. Instead, GIDs was closed and according to those sources, their work lied about in the report.

Ashleigh: Just as background, anonymous sources which we do not intend to name. So we will be making some comparisons between GIDS and these new services alongside our walk through of the care that’s recommended in the report. One Recommendation of the review was to prevent GPs from referring trans people to GICs in the first place, but to refer them to CAHMS (Child and Adolescent Mental Health Services) first.

Alyx: Now this isn’t new news, as in a previous consultation from the NHS, it covered this and we made a guide on it and we will link that in the description. So once you finally got referred, you would immediately be affected by the recommendations made by Cass. So to start things off, the first Recommendation was:

[page turning, classical music playing in background]

“Given the complexity of this population, these services must operate to the same standards as other services seeing children and young people with complex presentations and/or additional risk factors. There should be a nominated medical practitioner (paediatrician/child psychiatrist) who takes overall clinical responsibility for patient safety within the service.”

Ashleigh: Now we are told that in GIDs, this wasn’t done before. And to put it simply, Cass wants a doctor overseeing the care of the young trans person rather than therapists or psychologists. And there was some apprehension over the fact that this person who would take charge of this treatment would not previously have been trained in gender identity and would not have experience in working with trans people.

Alyx: So, immediately, this is showing Cass as trying to distance itself from GIDS, and further medicalise the process. And following on from this, in Recommendation 2:

[page turning, classical music playing in background]

“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.”

[classical music ends]

There were some long words in that one.

Ashleigh: So immediately warning bells were starting to ring for a lot of people saying that well, hang on, are you suggesting that being trans and being autistic are mutually exclusive, that you can’t be an autistic trans person? So that was definitely concerning. However as regards to the assessment for neurodevelopmental conditions, our contacts told us that this was already done and they had screened for a wide range of factors. Alongside neurodiversity, they mentioned identity, who the person is. They talked about family, talking about their life story, developmental information, hopes and wishes for the future, education, academic stuff, interests, their gender journey/story/history, talking about trauma and relationship with body and distress, talking about their mental health, relationships between all the interrelated things, their peer relationships, talking about gender and sex and all of that stuff. And using it to tailor care to the individual as Cass did suggest before. Yet Cass is framing it as if she invented it first or saying that they didn’t do this intensely enough.

Alyx: One part was also quoted to have been saying:

[page turning, classical music playing in background]

“They should also be aware of parent/carer expectations and the impact these may have on the young person’s priorities, or alternatively the potential for significant disagreement/fragmentation within families about the nature of the child/young person’s distress.”

[classical music ends]

Now this could be taken as either “put anti-trans parents first” or work on family counselling to ensure parents are more accepting, or be less evil. But we all know this depends on the intentions of the clinicians involved. Alongside this, in the Recommendations it is essentially recommending more intense screening for neurodevelopmental conditions and using what they would say, a “differential diagnosis”. And Reubs gave us their thoughts on that.

Reubs Walsh: A holistic assessment of their needs to inform the individualised care plan sounds great. It should include screening for neurodevelopmental conditions including autism spectrum disorder and a mental health assessment, on its own, what a good recommendation, yes it should involve all of that. What that shouldn’t mean though is that people whose needs are more complex or more urgent or more intense which are all overlapping and difficult to distinguish from each other, that those people should not be denied care. I do think that there is this, and actually after the first reading of it I thought that I found that she’d really said this and going back it’s really just implicit, this idea that autistic people are really susceptible to social influence and there’s a lot of places where she’ll make a point about autistic people are different in some way, usually quite a deficit-oriented way of saying that, and then the next thing she’ll say is teenagers are very susceptible to social influence. Now the reason she’s saying that is because she can’t say autistic kids, or it may not be the reason but she can’t say autistic kids are very susceptible to social influence because that is exactly the opposite of true. [laughter] That is false. Autistic people are less susceptible to social influence and that fact undermines every part of her argument that connects with this overlap so if she would address the question of autistic susceptibility for social influence her whole analysis would have to change but then she would have had to have read anything I’ve ever written or answered any of my emails or somebody like me.

Ashleigh: And in the Cass Review, it mentioned the tiered approach and essentially reads as a step-by-step which we’ll quote here. It:

[page turning, classical music playing in background]

“addresses urgent risk”

Alyx: “reduces distress and any associated mental health issues and psychosocial stressors, so the child/young person is able to function and make complex decisions”

Ashleigh: And it “co-develops a plan for addressing the gender dysphoria, which may involve a combination of psychological and physical treatment options.”

[classical music ends]

Alyx: Now that definitely sounds like a “deny until desistance” approach to us especially as it said to try reducing “distress and any associated mental health issues and psychosocial stressors”, then the next step is to treat the gender dysphoria. Section 11 also seems to obsess over pushing for talking therapies and obsessing over a one over the other approach where blockers and talking therapies can’t be used in conjunction with each other and pushing for an “alternative approach”.

Ashleigh: Then Cass uses a quote from a trans child that they spoke to who said “I think it’s helpful for people to know that there’s not only one route or one set way to transition or be trans. They might want just hormones, or just surgery, people are different with different experiences, presentations and bodies. It’s fine for that to be the case, it’s okay to have different plans for your medical transition”.

But this was Cass arguing that “trans kids want pathways that aren’t the usual pathway of hormones” when in reality, following on from the publication, the person who said this quote came out to say that this was taken out of context and was advocating to not remove the pathways that Cass was seeking out to advocate for. We will link that in the description.

Alyx: Following from that, in Recommendation 3:

[page turning, classical music playing in background]

“Standard evidence based psychological and psychopharmacological treatment approaches should be used to support the management of the associated distress and cooccurring conditions. This should include support for parents/carers and siblings as appropriate.”

[classical music ends]

I had a smile just after I said the psychopharmacological because I was like oh I said that first go.

Ashleigh: You did, nailed it!

Alyx: Now when Cass is talking about “psychopharmacological”, according to the Oxford Dictionary it means “the scientific study of the effects of drugs on the mind and behaviour.” So in this case what different drugs might have on someone’s psyche.

Ashleigh: And that it is, recommending to use standard evidence-based care to treat the conditions that isn’t dysphoria but this Recommendation doesn’t mention gender dysphoria yet, just the associated and co-occurring ones. So we think this would be doing things like prescribing antidepressants and anti anxiety medication for mental health conditions. Which on its face sounds like oh, yeah, that sounds reasonable. But that’s essentially saying no, we don’t believe – well, not that we don’t believe that being trans is a thing but saying that we can treat being trans with just antidepressants and if you want anything else you’re being unreasonable. We will come back to the way the Report does this at the end of the segment.

Alyx: So, we have been told that GIDS already worked with CAMHS on things like this previously. In fact, the method of collaborating with CAMHS that Cass endorsed is very unclear, mainly in the mechanism in which it goes about its “differential diagnosis”. How this is done is still a question. Would they discharge and make the child go through CAMHS before going back to the gender clinics, or is it that they will work with CAMHS, but keep them on? Or will it be all in house?

Ashleigh: Whichever way it goes, there is a large emphasis on diagnosing for gender incongruence before giving any care and the only way to do it is via a differential diagnosis. Alongside this, in our interview with Dr Cora Sargeant, a lot of “sort everything out first” is kind of unhelpful and Cora brought up the example of body dysmorphia.

Cora: When you’re trying to put a paediatrician or a psychiatrist at the heart of a holistic set of services for young people, if they aren’t well trained in understanding how these issues weave into each other then it could be that they start to see the idea of oh we need to make sure that a person’s neurodivergency is “treated”, in inverted commas, before they can access transition-related care or their mental health is treated or their eating disorders are treated before they can access transition-related care without realising of course that young people who are gender diverse experience eating disorders in part as woven into their gender dysphoria. Lots of young people experience eating disorders as a consequence of a society that has unrealistic and unachievable body ideals but for the trans community eating disorders can also be a way to manage a puberty that isn’t right for them. We covered this in an episode of Classroom Psychology last week, I think. Eating disorders are something that the trans community, young people, it’s a part of managing puberty and the changes associated with puberty when you can’t get access to transition-related healthcare. It’s also a way to feminise or masculinise our body in some way like trans guys using compulsive exercise to masculinise their body, especially when they can’t get access to medical treatment so the challenge here is kind of ironic, right? You’ve got a service set up that’s designed to potentially treat somebody’s eating disorder, maybe before they can get access to transition-related healthcare, we really hope that’s not the case but it could easily become the case and if that happens then it might be paradoxical in effect because giving young people less access to the transition-related healthcare they need, responsively, might lead them to use eating disordered behaviours as a way to manage the changes that are otherwise happening against their will with no consent from them, right, they don’t consent to the puberty that they’re being thrown down. I feel for them.

Ashleigh: Cora Sargeant, there, who is one smart cookie. Cora has a podcast of her own, Classroom Psychology, and she has done her own two-part deep dive into the Cass Review so you should check her out.

Alyx: Yeah that was a very interesting point that Cora made and alongside that in Recommendation 4, it says:

[page turning, classical music playing in background]

“When families/carers are making decisions about social transition of pre-pubertal children, services should ensure that they can be seen as early as possible by a clinical professional with relevant experience.”

[classical music ends]

When we spoke to our contacts, they raised the point that GIDS has no control over whether kids socially transition or not. They can’t just go “That’s a dangerous skirt!”.

Reubs had this to say about the discouraging of social transition, and the fact they wanted to make it a medical thing:

Reubs: From the summary: “76. The systematic review showed no clear evidence that social transition in childhood has any positive or negative mental health outcomes, and relatively weak evidence for any effect in adolescence. However, those who had socially transitioned at an earlier age and/or prior to being seen in clinic were more likely to proceed to a medical pathway.” By which they mean medical transition. “[77.] Although it is not possible to know from these studies whether earlier social transition was causative in this outcome, lessons from studies of children with differences in sexual development (DSD)”, which is a sanitised version of disorders of sexual development, better known as intersex conditions, “show that a complex interplay between prenatal androgen levels, external genitalia, sex of rearing and sociocultural environment all play a part in eventual gender identity.” So yes, that’s all fine, but you can’t then claim that we don’t know whether affirming someone’s gender identity through social transition is helpful or refusing to do so harmful. And you certainly can’t claim, as she does in 69 that the “intent of psychosocial intervention is not to change the person’s perception of who they are, but to work with them to explore their concerns and experiences and help alleviate their distress regardless of whether or not” the person needs to go for a medical transition. If there’s concern, which this “however there was no clear evidence of positive or negative” effects “however… they were more likely to proceed to a medical pathway”, is that a however, or is that an also by the way it was probably the people who socially transitioned were the ones who needed to socially transition because they were also the ones who medically transitioned, right, like there are so many other ways this can be interpreted but however suggests that the main way to interpret this finding is as a problem. There’s another bit, here, I’m really glad you’re editing this because it’s going to…

Alyx: Love you, Amber.

Reubs: “[66.] For the majority of young people, a medical pathway may not be the best way to achieve [wellbeing]”, that’s paraphrasing slightly, “for those young people for whom a medical pathway is clinically indicated, it is not enough to provide this without also addressing wider mental health and [psychosocial problems including these]”. Now, she’s Dr “We need evidence for things”, right, so where did she get this “majority” from?

Alyx: Right.

Reubs: And given that she obviously doesn’t have anywhere to get this “majority” from, is this claim that a medical pathway is not the best way to achieve wellbeing for that majority, is that not suggesting that there is some other way to achieve wellbeing and what might that be? I mean if it’s not conversion therapy, what is it? So it says again that the intent is not to change someone’s perception of themself, “[11.6] It is harmful to equate this approach to conversion therapy as it may prevent young people from getting the emotional support they deserve.” “[11.34] The Review also heard that some staff had looked at how standard evidence-based treatments (in this case third-wave CBT) could be used to help young people to manage their gender-related distress, stressing that this can be achieved without pathologising or changing a young person’s gender identity… However, this was not developed into a full research study”. You can’t have it both ways. You can’t say, on the one hand, we need evidence that this works before we can do it, and on the other, we don’t need any evidence that this works before we can do it.

And I don’t think you can say that you’re not advocating conversion therapy and then say that somebody can treat their gender-related distress with CBT instead of transition. That is conversion therapy. Applying CBT to gender dysphoria in a way that is not exclusively and explicitly about locating the problem where the problem exists i.e. in society and not in the individual and therefore is supportive of your desire to get treatments, so again we’re back to this thing of we’ve tried to put all these different responsibilities onto one person and you can’t, you actually need a separation of powers between the psychological care for the distress that a person is in, be it gender related or not, the assessment that is about trying to make sure that you provide care to people who are going to benefit from it and not to people who are going to be harmed by it and the actual care delivery. These are all things that need to work with a certain amount of independence from each other.

Ashleigh: So there were a few points raised there, and a lot of it does give the indication of conversion therapy. The whole part about emphasising CBT or Cognitive Behavioural Therapy is quite damning in itself and using that as if it’s an alternative to social transition. Now when we spoke to our contacts, they of course said that involvement of families was already a part of what happened at GIDS and a lot of it already under their “under 10s pathway” and was very keen to emphasise that that was a key part.

Alyx: They also made sure to mention that where it says “clinical professional with relevant experience” they immediately said the new services don’t want GIDS clinicians to be a part of it anyway, so they said that particular recommendation would be “impossible”.

Ashleigh: So we’re skipping over Recommendation 5 and going to Recommendation 6 which said:

[page turning, classical music playing in background]

“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.”

Alyx: In the recommendation it also said that the “puberty blocker trial should be part of a programme of research which also evaluates outcomes of psychosocial interventions and masculinising/feminising hormones”, “consent should routinely be sought for all children and young people for enrolment in a research study with follow-up into adulthood”.

Now this bit will be covered in the aftermath section but we wouldn’t be surprised of this being the reason the Scottish GIDS stopping prescriptions of puberty blockers after this review was released.

Ashleigh: According to our sources, GIDS already tried to give Cass their research data on psychosocial outcomes with interventions, but it was disregarded as we saw.

Alyx: Though as we know, GIDS definitely isn’t the best model, but we shouldn’t be deliberating on what the “least worst option” is regardless. There is concern in how GIDS did handle the healthcare of young trans people. For example, record keeping and a large number of other aspects. Our contact also mentioned that there was a lot that should have been improved and now we are in this position and with this bad record keeping, Cass now has an excuse to hold back puberty blockers because of this.

Ashleigh: So it says the research program needs to research puberty blockers and put it behind a research protocol but that would mean that it wouldn’t be a part of the standard treatment, just if the research protocol decides it wants to test it on you so even if you enrol, you aren’t guaranteed care with it.

Alyx: So the majority of kids probably won’t get blockers or anything and would have to wait to get to the adult clinic. Though with the recent announced review into adult care, that seems even less likely now as well…

Ashleigh: And when Cass went on to talk about lack of research into puberty blockers, she pointed to the effect of puberty blockers on trans kids’ brains. So let’s play the clip:

Reubs: I can remember the phrasing of this one because it was so bizarre. It was something like “other mood effects included a dampening of psychological function” [paraphrasing 14.52]. I don’t know what that means, I have a PhD in Psychology, I study this stuff, I know what I’m talking about, I don’t know what that means. Mood is usually, often, divided into valence and arousal, right, happier feelings and sadder feelings vs alert feelings vs sleepy feelings, is she saying that it results in people being sleepy? It is associated with a bit more sleepiness, so is puberty [laughter] but more sleep is not the same thing as a maladaptive suppression of psychological arousal. Also, if she’s saying, if there was a study – I haven’t seen one but maybe there is – that shows a difference in arousal when people are on puberty blockers, well, if we’re talking about trans people that’s to be expected because their anxiety levels will be lower and of course also we don’t have concrete evidence that their anxiety levels are lower but that doesn’t mean that that isn’t a reason to be sceptical that it’s like some kind of harmful effect of the medication either.

Alyx: And on the topic of downsides of puberty blockers, Cass mentioned about the issues in its effect on bone density so we also spoke to Reubs about this as well.

Reubs: I want to quote this and then I’m going to quote from the study that she’s citing. So this is in 14.43 “Multiple studies included in the systematic review of puberty suppression… found that bone density is compromised during puberty suppression, and height gain may lag behind that seen in other adolescents.” Height gain, I agree with, the systematic review they refer to is the one that they commissioned that was carried out by their specially selected cis people, and in that systematic review the specially selected cis person wrote “five studies found decreases in bone mineral apparent density and Z-scores pre/post treatment however absolute measures generally remained stable or increased or decreased only slightly. Results were similar across birth registered males and females. One study considered timing of treatment and found similar decreases among those starting puberty blockers in early or late puberty”. In the context of bone density, a Z-score is where you have standardised your estimate of bone density based on the age and gender of the person in question and so when you get to puberty, and first of all that’s when genders diverge, second of all that’s when you get a lot of increases in puberty that you don’t get before puberty, after birth and before puberty, in bone density. So these Z-scores, they’re telling you where they are relative to people who aren’t on puberty blockers at the same age. So given that puberty triggers an increase in bone density and we have blocked puberty, is this a surprise? Do we expect that this is going to be reversed with either the assumption of the endogenous puberty or the provision of an exogenous one? Yeah, that’s the right assumption and it’s also borne out by evidence. There’s also evidence to suggest that trans girls in particular have lower bone density before they start puberty blockers than cis boys of the same age for reasons that I think probably have something to do with access to participation in sport.

Alyx: And at one point suggesting and we quote:

[page turning, classical music playing in background]

“[14.55] Studies should evaluate whether simple measures such as stopping periods with the contraceptive pill have the potential to manage immediate distress, as well as other more conventional evidence-based techniques for managing depression, anxiety and dysphoria. None of these alternative approaches preclude continuing on a transition pathway, but they may be more effective measures for short-term management of distress.”

[classical music ends]

Ashleigh: It seems it’s saying “use the birth control pill instead of hormones or puberty blockers” and at points also saying that normal antidepressants and anxiety meds would be alternatives too as we mentioned a little earlier on and this is what Reubs Walsh had to say about this:

Reubs: At some point in this she talks about the idea that puberty blockers have become much more spread, fast, and with relatively little evidence, but unlike with birth control, when puberty blockers came on the market they had already been being used on children albeit different children with a different indication for decades. I also think that another reason why birth control spread quickly is because there was really a lot of demand for it because it gave people control over the most intimate aspects of their body and there are lots of reasons, like today in 2024 there are lots of reasons to be concerned about the long-term safety and efficacy of birth control, there’s a lot of unanswered questions, people who take birth control to prevent ovulation, there’s a lot we don’t know about the consequences of that and there is a lot of reason to think that there could be some really quite serious adverse ones. None of it compares to pregnancy.

Suicide is a pretty big adverse event. When I was preparing this part of my notes, I spent ages trying to dig it up but I can’t remember which one it was, but one of the studies from the Dutch clinic in adolescence, treatment as usual vs puberty blockers I think, in any case they had one patient they mentioned who committed suicide during the course of what was not a very long study who had been placed in the no treatment group for a variety of reasons and they used this, they mention the suicide and use it as an explanation for why they were right to classify that person as not suitable for care. And there is also evidence that if you look at the number of suicide attempts, it’s self-report, but people who asked for puberty blockers and were denied them in adolescence have a higher rate of suicide attempts than even people who didn’t come out until adulthood. So having a sufficiently intense awareness of let’s use gender incongruence for now, or your transness, having that awareness earlier… I don’t necessarily know that it’s actually all about gender, at that point it could be that they’ve figured out what they want and it’s about their body and it’s happening and it’s out of their control and there’s somebody who has the ability to give them back control who is refusing and that is traumatic, that is violent. There’s also data to support the idea that if children ask for puberty blockers and you say no, there is a risk of suicide from that. And that’s a very serious adverse event so like birth control, like abortion, the alternative to not providing the treatment comes with significant adverse events, significant risk, that outweighs, I would argue anyway, the risk of providing the treatment.

There’s also the fact that so far it’s relatively rare for people to procure puberty blockers from outside of a regulated medical pathway but it will get a lot more common now that new prescriptions have been banned. It just will. That’s what’s always happened, it’s what happened with abortion, it’s what’s going to happen and as the Cass Report rightly notes, these sources of medications are incredibly unsafe. I really think that, while we’re doing the analogy, how do we think people would react to a review, I mean some people would react very well to it unfortunately but a lot of people, most people, normal people would react to a review that had only cis men and specifically cis men who didn’t have any experience in obstetrics deciding about the safety of birth control and abortion because if you’re a woman or an obstetrician that makes you biased. Just to hammer home how much this analogy applies, in 14.55 she suggests that for AFABs who are distressed by menstruation, ignoring all of the other things that are distressing about wrong puberty in that direction but birth control is a viable alternative and I agree from the point of view of if there’s a clinician listening who is now going to try and figure out how best to take care of patients who are getting very distressed about menstruation, birth control is a good alternative given than puberty blockers are now not an option. But if puberty blockers are an option, I don’t think that the safety question is any different between the two.

Alyx: Following this, we’ll then go to Recommendation 7:

[page turning, classical music playing in background]

“Longstanding 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.”

[classical music ends]

Ashleigh: Now, again, this was apparently already done at GIDS, but there are now doubts over the use of gender dysphoria as a diagnosis because it’s becoming more and more outdated. And of course, Reubs had this to say.

Reubs: Gender dysphoria as a diagnosis doesn’t describe some psychological state in which your gender becomes fragile. I mean, we’d have to diagnose an awful lot of cis people with gender dysphoria if that was what it meant. In fact, what it means is being trans and part of the reason I have so much to say [laughter] about the diagnostic definition of gender dysphoria in the DSM is that I’m aware of and tangentially involved in a project to remove gender dysphoria from the DSM on the grounds that the diagnostic entity as it currently exists is, well, incoherent for a start. Except that the usual way to do that of course would be to respond to the evidence base of the original introduction of the diagnostic category, but since that was done before they had these evidentiary criteria, instead, we’re providing evidence that it is, you know, diagnostically sensible not to have this category in a format that’s really designed for people putting forward why it makes sense to have a diagnostic category.

We can also take it back to the stuff that’s around puberty blockers and the evidence there as well, right? But often the evidence that’s required to change something, to change the status quo, is sort of disproportionately greater than the evidence that established that status quo. Or even the evidence that there is to maintain that status quo.

Alyx: So after this in Recommendation 8:

[page turning, classical music playing]

“NHS England should review the policy on masculinizing/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.”

[classical music ends]

Ashleigh: So it seems the Cass review is still fine on people being prescribed hormones, kind of, even if they are making the case that someone should wait until they’re 18. And for this the age of 18 really is arbitrary. And it seems to obsess over the constant mentions of brain maturation. And we spoke to Reubs again who walked us through this.

Reubs: There’s a bit where she says: “[83.] Moreover, given that the vast majority of young people started on puberty blockers proceed from puberty blockers to masculinising/feminising hormones there is no evidence that puberty blockers buy time to think, and some concern that they may change the trajectory of psychosexual and gender identity development.”

Unless you can show that this route of taking puberty blockers first has a higher rate of regret – and just to be clear, I mean regret, with or without re-trans or de-transition – then the only way to claim that this changed trajectory is a concern is if being cis is a better outcome. Adolescent development is incredibly delicate. And I mean people who are ahead of their peers, in terms of pubertal development, do a lot worse psychologically in the long term. And that we know. In terms of people who are behind, the evidence is less clear, you know, it’s much more equivocal, and I think it probably depends on the individual quite a lot more, whether that’s a good thing or a bad thing to be surrounded by people who are more developed pubertally than you.

Whatever the case, I do think that when you’re in a cultural context where you undergo development synchronously with most of your peers, most of the people who are close in age to you, who you spend time with, you’re really in synchrony with them because of the way our school system works. And there are other reasons to be worried about it as well, just in terms of we don’t really know what happens if you do things for longer than we’ve done them before before. So that does worry me. But then I want to go back to, well, why are we using puberty blockers in the first place, right, because there’s this line that, you know, there is no evidence that puberty blockers buy time to think.

And some concern that they may change the trajectory of psychosexual and gender identity development. So yeah, I actually agree that they are not buying time to think for the patient. The original context that they were introduced in, in the Dutch context, was that clinicians and parents were not ready to proceed with the usual treatment programme of replacing the endogenous puberty with one that was identity congruent, i.e. what they used to call cross sex hormones right? It was really about the fact that there were children in that service who were putting their clinicians and their parents in the position, or whose need to be well, put clinicians and parents in the position of it really not being a viable option to let them just go through endogenous puberty, as had been the normal practice up to that point.

And sometimes people were being put on exogenous hormones to induce a puberty. But a lot of parents understandably were very hesitant about that because it is less reversible than puberty blockers, and so they were put on puberty blockers for about a year to give them and their parents and let’s be honest also their clinicians and to some extent policymakers to get the ants out of their pants and calm down about it. It really, really did come from that kind of harm reduction place and as a compromise between very insistent patients, their variably supportive parents, and quite conservative clinicians.

Alyx: We really like Reubs. We keep going back.

Ashleigh: We love Reubs. An extremely, what do you call it? An eloquent speaker, unlike me, failing to remember the word eloquent.

Alyx: After this we skip Recommendation 9 and we go to Recommendation 10.

[page turning, classical music playing in background]

“All children should be offered fertility counselling and preservation prior to going onto a medical pathway.”

[classical music ends]

Alyx: But this is already done at GIDS anyway, so moving on to Recommendation 25.

Ashleigh: We’re skipping over a few there, we realise, but there are only so many hours in a day.

Alyx: And most of it wasn’t relevant to Part 4.

Ashleigh: Yes, Recommendation 25.

[page turning, classical music playing]

“NHS England should ensure there is provision for people considering detransition recognising they may not wish to reengage with the services whose care they were previously under.”

[classical music ends]

Which, again, has been done under GIDS anyway.

Alyx: According to our sources. So now we move on to 26, not skipping too many there.

[page turning, classical music playing]

“The Department of Health and Social Care and NHS England should consider the implications of private healthcare and 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.”

[classical music ends]

Ashleigh: And this is where it has quite a few people worried when it comes to this. And in the Cass Review, it is vague about what GICs should do if a child is using a private service. It doesn’t say to discharge them or refuse treatment till they come off of it. The only thing they said was if an individual were to have taken puberty blockers outside the study, their eligibility may be affected, which is kind of vague and kind of ominous at the same time.

Alyx: However, one recommendation is very targeted and that would be in Recommendation 27.

[page turning, classical music playing]

“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.”

[classical music ends]

And this would directly be towards people who use GenderGP and those are the specific recommendations in regards for Part 4. The rest of the recommendations for Part Five are more about provisioning. So what are your thoughts on that?

Ashleigh: Well, there’s a lot in there, isn’t there? With all these recommendations so what a lot of people bring up is that the Cass Review as a whole is not, you know, an academic paper. It’s not been peer reviewed itself. Fine, it’s done some studies which have been incorporated into the dataset by the University of York. But as a whole, this piece of work hasn’t been peer reviewed.

Alyx: And what muddies that, what they often use to muddy this is that the opinions made from it are derived from those multiple different studies that have been peer reviewed but that doesn’t make the conclusions that Cass made any more scientific. It’s just her and her team’s opinion after reading all of these papers. And in a lot of ways, even purposefully misinterpreted them to be different to what the papers actually said.

Ashleigh: Yes, which we covered a little bit earlier on, didn’t we? And don’t forget all of the research that they excluded.

Alyx: Yes, exactly. As Cora said a few times and the research methodology, they purposefully muddled up.

Ashleigh: Chose to exclude, yeah. Well, it wasn’t even that they muddled it up. They excluded 90-odd percent of all of the available evidence, deciding that it was low quality because it wasn’t a randomised controlled trial, or RCT, as a couple of our interviewees have referred to it as. On that basis they haven’t included it as part of the work in the Cass Review. And, to me, that is such a huge problem because as Cora said, if you’re using a low quality study, there are ways of correcting for that. The fact that they’ve chosen to completely exclude that, I feel it tells of an agenda.

Alyx: Exactly. And it’s that through line that we’ve brought through the last part, which was that the methodology brought was by a Tilly Langton, of the consultations with Patrick [Hunter]. So when you look through all the recommendations for the care you just need to keep an eye out for the exploratory approach that this Review seems to go through and then think about the research methodologies as well and the motivations and philosophy. You can see how it precipitates the whole of Part 4.

Ashleigh: Yeah, absolutely. That throughline of trying to make it as obtuse and difficult as possible, and unfortunately things don’t get any better on that subject in Part 5.

Alyx: It’s also interesting to mention earlier in one of the recommendations it still included in the research protocol about hormones treatment, which most people would have just considered it an absolute blanket ban because it’s the Tories anyway.

Which, even if it’s behind a research protocol, was still a bit strange, but it’s still a shit review anyway, but that’s just a little talked about thing that I just found a bit huh? Once we stopped talking about the care that there was, I suppose we’ve got to look at the logistics of how they want to go about providing this “care”.

Part 5

Ashleigh: Which brings us on to Part 5.

[classical music playing in background]

The service model “considers the gender service delivery model, workforce requirements, pathways of care into the specialist service, further development of the evidence base and how to embed continuous clinical improvement and research.”

[classical music ends]

Alyx: In this section, we’ll have a talk about some of the “provisioning of care” that the review advocates for, which seems to make the process even more difficult and obtuse than it already is. The first big fat red flags are that GPs will no longer be able to provide referrals to a gender service, and that gender service is extremely unlikely to provide any meaningful treatment i.e. blockers and hormones without being put on whatever their research protocol is first.

Ashleigh: So we had a chat once again to Reubs Walsh about this.

Reubs: As far as I’m concerned, this is crackers because where is the caution about subjecting trans kids to the wrong puberty. Such a delicate stage of development. Sixteen is too old of a limit. Puberty blockers in trans kids basically exist to avoid having to admit that.

Ashleigh: We also want to highlight this little gem from section 94. “Although retrospective research is never as robust as prospective research, it would take a minimum of 10 to 15 years to extract the necessary follow up data.” So are you saying that’s 15 years of your research-based model or 15 years of analysis once it’s complete, what are you talking about when you say this is gonna take 10 to 15 years? Because that’s a long fucking time to not get any meaningful gender treatment.

Alyx: There is certainly an emphasis in some parts where it bases its success on whether they are working in a job or not rather than whether the person’s happy. It seems to say it wants to lower the waiting list but does not define how is this to be done given how no one would be getting any meaningful treatment now anyway? And how do you plan to reduce waiting lists for the treatment you’ve just made it much harder to access?

Ashleigh: It’s also preventing GPs from directly referring a child to the gender service, jamming one more wrench into a system so stuffed full of wrenches you’d think Baron Harkonen had taken to eating metallurgical snacks.

Alyx: Did you watch Dune last night or something?

Ashleigh: No, I didn’t, but I reread it recently. I think that’s part of me saying oh you should watch Dune Part 2 actually because I’ve not watched it yet.

Ashleigh: Yeah, Part 1 was excellent.

Alyx: We also need to talk about how the Cass Review affects the regional services. Another element mentioned in Section 5 includes something we here at What the Trans and many others considered to be outside the scope of what the Cass Review was supposed to talk about.

The Review advocates that young people who would have or already have aged out of the service while on the waiting lists should be looked after “either by extending the range of the regional children and young people services or through linked services”. Nice idea in theory, but this was seen as something of an overreach by critics of the Review.

So we spoke to Reubs who had this to say about it.

Reubs: In common with other people who’ve made this argument before, it just fundamentally misunderstands the literature on adolescent development. Adolescence is from a neurodevelopmental point of view, the beginning of adult-like neuroplasticity. At the beginning it functions differently. It different manifestations and effects, but essentially, it’s a transition from a childlike type of neuroplasticity, toward an adult-like type of neuroplasticity along with shifts in your motivations and priorities that make sure that that plasticity is used to equip you to cope in the social world that you actually exist in and not you know, whichever one it is you might have been dreaming about in your childlike ideations.

So there’s really a fundamental misunderstanding of what it means to say that adolescent like neurodevelopment continues for as long as we have studied it, which is what the finding actually is. It’s not that we found that it carries on till 25, it’s that we found that it doesn’t stop and we looked until they were 25. So that’s what’s really going on here. And I think there probably does come a point where your neuroplasticity starts to look more like ageing and less like the continued development. But, depending on where you live, it could be anywhere between early 30s and mid to late 60s, 70s even.

Ashleigh: So there are a lot of questions about how exactly the research that they’re advocating for is going to be conducted because that’s not any information that’s been put out there yet. What’s this research protocol going to look like? Who is it going to be through? How well funded is it going to be? How long is it going to take? Because if they’re saying that we won’t be issuing puberty blockers outside of a clinical trial, it’s kind of strong-arming people into a clinical trial, which then means that that’s not really informed consent. And that is…

Reubs: Unethical, surprisingly.

Alyx: The good old coercion method.

Ashleigh: Yep, it’s a classic.

Alyx: There’s also effects on private healthcare, the blocking of people being able to access it or not blocking it.

Ashleigh: What effect exactly does that have on private healthcare? If you’re saying that you’re going to stop private healthcare from being able to prescribe puberty blockers and hormones to those who are not getting it because their clinical trial hasn’t been started yet.

Alyx: There’s also a particular emphasis on the preventing of overseas care, like a considerable amount and a lot of this, everyone just immediately points to GenderGP. But there’s also the aspect of like, what about people who immigrated over to the UK? And what about people still getting health care from their home country, that’s going to strongly affect quite a few trans people that way, which is horrid to think about, that they might be denied the care they have. There’s been no clarification over how that would work or any indication over their intentions over that.

Ashleigh: You know, as we’ve said, there’s so much of it that has, that says, oh, we’re going to do this, but it’s not explained how it’s going to do this, but it’s already had a knock-on effect. Like the gender service in Scotland saying “okay, we’re going to stop prescribing puberty blockers”, even though the pathway for this research protocol hasn’t been explained, the information has not been released, so anybody who is waiting for puberty blockers as part of the Scottish Gender Service is now just kind of waiting in limbo as puberty marches on and that’s a really shitty thing to do.

Alyx: That was the Cass Report, ignorance towards evidence, a push for making trans kids’ lives worse, and the plan to implement it in tatters before it was even published. This is the legacy of the Cass Report. And now, after the publishing of the Report, the complete and utter failure of the response to it from those in power, those in opposition and some who campaigned for us. So we’re just going to have a look at the fallout of the Report.

Ashleigh: So even before the Report was formally published, its contents were leaked. We got our copy a day early thanks to this really awesome friend of ours in the media.

Alyx: A really awesome person. And immediately concerns were raised and other trans folk came out in force to really show their thoughts on it.

The main fallout comes a day or so after the report was formally released and from the get-go, it was a gigantic media circus and transphobes were all over the news. And according to some folk they received an advance copy days before any trans outlet got theirs.

Ashleigh: And I think we need to point out as well that the review has done a reasonable job of seeming to be respectable and empathic. Like how it brings up the potential of some kind of follow-on service for 17 to 25 year olds, which sounds kind of like a good idea, or the claim that it wants to bring waiting lists down, which is, you know, another good idea. There’s just enough ostensibly good stuff in there that a layperson could read it and say, well, I don’t see what the problem is, it’s suggesting this and this and that, why are you transes never happy? We’re pretty sure that this aspect is why several LGBTQ organisations released quite underwhelming statements about the Review within that first couple of days.

Alyx: So when Stonewall released a statement, it said the Cass Review can play a vital role in achieving this aim if its recommendations are implemented properly and that they urge NHS England and policymakers to read and digest the full Report and consider Dr Cass’ plea to remember the children and young people trying to live their lives and the families or carers and clinicians doing their best to support them all should be treated with compassion and respect.

This, unfortunately, was a very lacklustre statement and was not received well, and while it didn’t say they welcomed the full Report, it felt like it could be even stronger.

Ashleigh: So following this, the Feminist Gender Equality Network put out a more strongly worded letter stating that “the Cass Review contains unsound methodology, unacceptable bias, and unsupported conclusions. As academics and experts in the field, we regard the Cass Review as potentially harmful to trans children.” And there was much outcry from other trans supportive and trans outlets, including ourselves, of course, who pointed at the connections to conversion therapists that we laid out early on in this big Cass Review digest.

Alyx: And even following that, on 18 April, it was announced that Scotland’s gender identity clinics paused all future prescriptions to puberty blockers, and only those who had previously been prescribed will receive them. And this, understandably, sparked outrage in the trans community and the following weekend a protest was staged outside the clinic.

Ashleigh: Another knock on effect was the news that a review into adult gender services along the same lines as the Cass Review is being planned as published in The Guardian. As we’ve said for I don’t even know how long now, once they’ve halted young people’s ability to transition, they’ll come for the adults next. We’ve seen this exact same thing play out in America, where people like Patrick Hunter are the ones influencing and even just writing chunks of new anti-trans legislation.

Alyx: Now with all this, professional bodies were still digesting the report, chiefly amongst them was WPATH and EPATH who made their own thoughts known a few weeks later. So in a lengthy statement it said that WPATH and USPATH remained deeply concerned about the facts regarding the Cass Review’s process and content, as well as its consequences for the provision of care for trans and gender diverse youth. It also said it was concerned about a number of aspects. The first was the appointment of Cass onto the board and points to the fact that the process was without transparent or competitive process and that Hilary Cass is a paediatrician with hardly any clinical experience or expertise in providing transgender healthcare for young people. Furthermore Hilary Cass lacks significant research qualifications or research expertise in transgender health.

Ashleigh: They also called the Cass Review an outlier, ignoring more than three decades of clinical experience in this area, as well as existing evidence showing the benefits of hormonal interventions on the mental health and quality of life of gender diverse young people. They then went on to say that WPATH and USPATH also have serious concerns regarding the ethics of the provision of puberty blocking agents for the young TGD people in the United Kingdom in the context of a research protocol only (TGD being trans and gender diverse people).

Alyx: Two days prior to this statement, the government issued its new RSE guidance.

Section 28

Alyx Bedwell: With this sort of ban that they’re considering, it has always been cited, but they always keep citing the Cass Review. And this wasn’t the only thing that cited the Cass Review as why they wanted to implement a specific ban, and one of them could be considered what some people call “the new Section 28”.

Ashleigh Talbot: So you’ve probably heard about this one already, it was unavoidable last week. Side note: trans news used to be a few pages in, in smaller text, usually about some trans person apparently being the first to do something. Now it’s omnipresent, and that is so exhausting. So, this week’s stressful, inescapable news is that there is a plan to ban all mention of trans people during sex and relationship education at schools. A new Section 28, basically, aimed squarely and specifically at trans people, which is something that we have been warning about for literally years at this point. I hate being right all the time.

Alyx: I know, it’s so difficult.

Ashleigh: At the moment, this is some planned guidance for schools. On the 16th of May, the government confirmed that sex education for children younger than nine and any education about trans people for all pupils will be banned once their legal guidance is updated. This doesn’t come to a vote in the Commons or anything, this is an update to guidance, so it is something that they can just do. Not that there would be much opposition in the Commons, as it stands at the moment, of course. Although Nadia Whittome, who’s a Labour MP, has openly criticised the plan, saying “sex and relationship education is vital for helping to keep children and young people safe and healthy. It is already taught in an age-appropriate way by schools. The Tories’ claims about what children are learning are designed to fuel hysteria and build support for Section 28-style policies – which is what this latest guidance seems to be harking back to.”

Alyx: Indeed, because the guidance is a continuation of the government’s tired game of whack-a-mole in trying to extinguish any and all notion of trans existence. Those in secondary schools will supposedly be taught about the legally ‘protected’ characteristics of sexual orientation and gender reassignment. But teaching gender reassignment without first establishing the base of trans identity goes beyond putting the cart before the horses. Instead, it teaches kids about the cart without acknowledging the existence of horses or their necessity in pulling carts. This new guidance preaches safety, but simultaneously denies the education of children about sexual violence until they are in Year 9, neglecting to consider children who experience sexual violence at younger ages. Instead of abuse, children first learn about conception and birth in Year 5, keeping in line with the heteronormative, conservative values the Tories are keen on upholding.

Ashleigh: The gov.uk press release of the guidance mentions the Cass Review, of course, which, at time of writing, is only six weeks old, explaining the guidance’s kind of rushed feel. With no need for parliamentary approval, this is another cheap ‘win’ for the government, added to the pile of half-baked legislature made amidst the general election-induced panic, senselessly cobbled together with tape, chewing gum and bigotry. The Cass Review’s suggested medical restrictions clearly stirred a feeding frenzy among the lights of Miriam Cates and Gillian Keegan providing just enough crumbs of ground to justify imposing similar restrictions in the classroom.

How interesting that the guidance claims to advocate for science all while still adhering to the antiquated and awkward “rolling condoms over bananas” metaphorising of human anatomy. If Keegan is so set on accurate education regarding sex organs, she should first consider the repercussions of having children compare their bodies against whatever you find in a fucking fruit bowl.

Alyx: In an exclusive ‘What The Trans?!’ interview, nonbinary sex educator and soon-to-be author Dee Whitnell warns that this will lead to a complete depletion of trans educators. “As an ex-teacher, what would I have to do?” they asked. “Would I have to erase my own identity in the classroom? Not explain why I use they/them pronouns, why my honorific is “Mx”?. Would I be fired for doing so? It makes no sense to me.” Dee worries that this changing guidance endangers trans students who are already out in their schools. “How will their identities be discussed in the classroom? Will they be silenced, erased? When talking about safe sex practices, will anyone provide resources that are inclusive for them? Will they have to sit in a classroom with their “biological sex” and have to experience misgendering the entire lesson?” Dee assures that they will be fighting every step of the way in the eight week consultation period, fighting for and alongside the trans children the guidance fails to protect. Though, they fear what else this might spell for trans erasure beyond the classroom.

Trans author and activist Kestral, in another ‘What The Trans?!’ interview, likewise forecasts dark days ahead, claiming what little progress has been made in the years following Section 28 being repealed in 2003 will return tenfold, traumatising an entire new generation of trans youth. The new guidance, according to Kestral, will undoubtedly prove vindicating for educators who still incubate prejudices carried over from the heyday of Section 28 as she pronounces during her interview. “We’re in a place where hate is, once again, on the agenda.”

Ashleigh: So, yes, that’s a lot of stuff we just threw at you. But yeah, this is not good. It’s not a good look. The fact that it doesn’t have to go through parliament and they can just do this is of some concern, I think, because once it’s in, it might be quite difficult to get it out? You know, not without getting someone, or several someones, to have to completely rewrite the guidance, and so chuck out that guidance and replace it with something new. But then that does mean that you have to come up with something new to replace it and say “well, we’re going to chuck that out and replace it with this”. So you need it, essentially, rather than just saying “okay, we’re going to ditch that specific bit of the guidance”, which I’m sure educators will really appreciate that political tug-of-war.

Alyx: So, according to The Telegraph on 16 May, Labour had declined to commit to keeping the new sex education guidance for schools, and both Keir Starmer, the party leader, and Bridget Phillipson, the Shadow Education Secretary, fell short of promising that the guidance unveiled by the Education Secretary would be kept if they were to win office. The Health Secretary did stress the importance of age-appropriate teaching and also saying that it was important to provide different lavatory facilities based on “biological sex”, which is a bit iffy there. She wants to look carefully at what the government is setting out. It’s a draft consultation and there’s a consultation.

Ashleigh: There’s always a consultation.

Alyx: Always bloody is.

Ashleigh: If it goes the way of everybody or most people who write into it say “hey, look, this is a shit idea, and you shouldn’t do it” they’ll still bloody do it.

Alyx: Yes, I’ve just finished reading it. So it sounds like they haven’t committed to keeping the guidance or following through with the guidance if once they come in, so they could just leave it dead in the water or say, “no, we’re not going to…”

Ashleigh: Yeah. “We’re not going to make that change.”

Alyx: We’re not gonna make that change.

Ashleigh: Yeah.

Alyx: But the problem is you have to see whether Labour makes the decision for themselves. And at the moment, it’s becoming very difficult to trust Labour with our own education, or lives, or anything. But with that, I suppose, the fact they’re not committing to anything for fucking once is a glint of something. Even if it’s a crap-tonne of nothing.

Ashleigh: Yeah. That’s infuriating, isn’t it? But on the subject of the election, we’ve got a whole episode planned for it. So within the next few weeks, obviously, the election is only a few weeks away, so our next episode is going to focus on it. We’re going to have a look at the manifestos. We’re going to have a think about who should we vote for. Annoyingly, in some places, it might be necessary to vote tactically, which might mean that in some places the way to stop the Tories… which is the most important thing… the way to stop them might be to unfortunately hold your nose and vote for Labour. Um, which sucks, and there should be a better alternative, but there isn’t because we’re in the worst timeline and the UK just needs to die as a concept. Now we’re getting onto the whole idea of nationhood and states, which also needs to die as a concept, but don’t get me started on that. So yes, look forward to that. An episode all about the election. Won’t that be fun?

Alyx: As if we hadn’t done enough writing as it is.

Ashleigh: Yeah. Yeah. Keyboard’s just about cooled down.

Alyx: Yeah. I mean, what if we had just some nice little story about a nice play that was going on in some theatre or about Abigail Thorne or Star Wars or trans actors appearing in Doctor Who? But no, we have to talk about the new Section 28 for trans people.

Ashleigh: Yeah. Yeah, worst timeline. Worst fucking timeline.

Alyx: And of course they always blame the Cass Review on this.

Ashleigh: But this is an example on the wide-reaching implications of the Cass review, and this is regardless of whether the people who made the decisions read them properly or with good intentions. It’s used as an excuse to make our lives worse regardless or not of the contents.

Alyx: And what we have found out from Susie Green is the effect this will have on trans kids, including the effective ban on puberty blockers. We are going to have to issue a content warning again for suicide. On 2 May Susie Green, ex head of Mermaids, put out a tweet stating that since the Bell v Tavistock ruling, 16 children have died from suicide. A year prior the number was one child.

Further on from this, she asked how many more kids must die before a direct correlation between denial of service and death by suicide is recognised and stated that the faux concern “and what about the children” is a smokescreen for bigotry. The UK is ignoring all the evidence that proves gender affirmative care saves lives, and this is what is at stake with this Cass Review.

Ashleigh: Now all of this is terrifying, and we know that there are going to be some trans kids who do listen to this podcast. Thank you guys and gals and nonbinary pals. And we just want to say this. We are worried and angry for you. Every adult in the room is worried too, trans or cis, and we are fighting to make sure you get the best care that you can get. We and so many others are working to at least try to make sure we can keep you safe and defend your healthcare.

The battle might appear to be lost, especially with an incoming Labour government saying they will stick with the Cass Report as a road map. But this is just one battle in a much larger culture war, and we will never stop fighting for your rights and ours to be us, to be ourselves, to be free.

Alyx: And if you haven’t already, let us radicalise you to get involved. Change only comes when people work towards it. You can find or form mutual aid groups. You can write to your MP, stage protests and get your cis friends to join us in solidarity. Join an anarchist collective, make protest art and staple it to a cabinet minister’s clothes. There’s so many options. We are with you, we love you and there’s always still hope. We have to believe that.

[Thanks and end from 105]

Ashleigh: Thank you so much to Cora Sargeant, to Cal Horton, to Reubs Walsh and to Natacha Kennedy. You’ll be hearing more from some of them next time as well. But, couldn’t have done this without you guys, love you mwah mwah. But yeah we hope that’s been sort of helpful to go through it in order and kind of explain where some of the thinking has come from and what seems to have influenced it. So watch this space, there will be more of this, in two weeks’ time.

Alyx: With episode 106.

Ashleigh: Episode 106, yes indeed. If any gender clinicians past or present would like to come and talk on the show to talk about the Cass Review, please do get in touch. We are focusing on Parts 4 and 5 of the Review, and we would like your insight. We can quote anonymously, if you don’t want to be quoted your insights would still be appreciated as an off the record chat. So, do pass that around, we would be very interested in having a perfectly reasonable discussion with somebody to get your insights.

That’s basically us. Thanks for checking us out, thanks for listening all the way to the end of the episode. You can find out all about the work that we do on our website, whatthetrans.com. Obviously we’re on Twitter, we’re on Bluesky, we’re on Instagram, we’re on Facebook. If you’re able to support us or share us on Patreon, fantastic! That’s what allows us to do all of this stuff. But for now, thank you all very much for listening and we’ll see you next time. Buh-bye!

Alyx: Bye!

[End of show spiel]

Ashleigh: This episode of “What The Trans?!” was written and produced by Ashleigh Talbot, Alyx Bedwell and Amber Roberts, and edited by Amber Devereux. And with our opening theme composed by Waritsara Yui Karlberg. We would especially like to thank our producer-level Patreons, who are…

Ashleigh and Alyx: Katie Reynolds, Georgia Holden-Burnett, Grabilicious, Alex T, Rootminusone, Grey, Elisabeth Anderson, Bernice Roust, Ellen Mellor, Jay Hoskins, Trowan, Ashley, Matty B, Squidzina, Setcab, Jane, Roberto de Prunk, Rose Absolute, Sarah, Sina, Kiki T, Dee, Skye Kilaen, Eric Widman, Bee, Jude, monsieur squirrel, Fergus Evans, anubisajackal, Camina, Brandon Craig, braykthasistim, Sian Phillips, Heidi Rearden, Ezra, Sophia VI, Lentil, Philippa Taprogge, clara vulliamy, Amelia, Corvina Ravenheart the trans metal DJ from Twitch and VR chat will play St Lucifer for props ([snaps] – props to you babes!), Tabitha Jo Cox (AKA Candy), Fiona Macdonell, Torikuso H, Murgatroid, ontologicallyunjust, Stella, Cyndergosa, Rebecca Prentice, CRAZZEE RICHARD, danoblivion, Florence Stanley, TheCthulhuKid, Helen_, Elle Hollingsworth bought too many magic cards, Nick Ross, Melody Nyx, Fiona Punchard, John, Nick Duffy, CB Bailey, Gordon Cameron, Ted Delphos, Wen Riverop, Vic Parsons, Patreon User, Vic Kelly, Katherine, Sabrina McVeigh, Cassius Adair, Melissa Brooks, Karaken12, April Heller, Sofie Lewis, Alexandra Lilly, Claire Scott, Ariadne Pena, Lauren O’Nions, Bernard’s Pink Jellybean, Leynos, Chris Hubley

…thank you to you all! Thank you all, byee!

[Thanks and end from 106]

Ashleigh: We want to thank all of the people who helped us with the reporting on this Review. It has been one of our most complex productions we’ve ever had. So we just want to thank Kai, Luci, Milo and Rowan from what we’ve been calling our consultation team for their analysis piece when the report first came out and for speaking with us on the pod, and Trans Safety Network for assisting them and providing them with some fantastic intel on the connections that the Cass Report had with conversion therapists.

Alyx: And we want to thank the folks who wish to remain anonymous for speaking with us about the NHS care and the information around that.

Ashleigh: And finally, we want to thank Dr Cora Sargent, Dr Reubs Walsh, Dr Natasha Kennedy and Dr Carl Horton for their fantastic insights that they all had and for helping advise us when we were doing all of this writing and for speaking with us on the pod.

Alyx: And we really appreciate it and hopefully we have all kept you all informed and up to speed on what this infernal report was. And with this information we’ve given you, help you fight this. And whilst this culture war wages on, we can help provide you with the information to fight it.

Ashleigh: This episode of What the Trans?! was written and produced by Ashley Talbot and Alex Bedwell and Honor Wilson, and was edited by Amber Devereaux and with opening music composed by Waritsara Yui Karlberg. We would especially like to thank our producer-level Patreons, who are…

[end credit music begins]

Ashleigh and Alyx: Katie Reynolds, Georgia Holden-Burnett, Grabilicious, Alex T, Rootminusone, Grey, Elisabeth Anderson, Bernice Roust, Ellen Mellor, Jay Hoskins, Trowan, Ashley, Matty B, Squidzina, Setcab, Jane, Roberto de Prunk, Rose Absolute, Sarah, Sina, Kiki T, Dee, Skye Kilaen, Eric Widman, Bee, Jude, monsieur squirrel, Fergus Evans, anubisajackal, Camina, Brandon Craig, braykthasistim, Sian Phillips, Heidi Rearden, Ezra, Sophia VI, Lentil, Philippa Taprogge, clara vulliamy, Amelia, Corvina Ravenheart the trans metal DJ from Twitch and VR chat will play St Lucifer for props ([snaps] – props to you babes!), Tabitha Jo Cox (AKA Candy), Fiona Macdonell, Torikuso H, Murgatroid, ontologicallyunjust, Stella, Cyndergosa, Rebecca Prentice, CRAZZEE RICHARD, danoblivion, Florence Stanley, TheCthulhuKid, Helen_, Elle Hollingsworth bought too many magic cards, Nick Ross, Melody Nyx, Fiona Punchard, John, Nick Duffy, CB Bailey, Gordon Cameron, Ted Delphos, Wen Riverop, Vic Parsons, Patreon User, Vic Kelly, Katherine, Sabrina McVeigh, Cassius Adair, Melissa Brooks, Karaken12, April Heller, Sofie Lewis, Alexandra Lilly, Claire Scott, Ariadne Pena, Lauren O’Nions, Bernard’s Pink Jellybean, Leynos, Chris Hubley

[music ends]

Alyx: Thank you for watching, bye!

Ashleigh: Thank you for watching?

Transcript

Part 1

Part 2

Part 3

Part 4

Part 5

Section 28

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