Social Transition, Puberty Blockers and the Cass Review (Podcast transcript)

Hello, my name is Dr Cal Horton, I’m a Research Fellow focused on the experiences, rights and well-being of trans children. I’ve been deeply immersed in the literature on this topic for many years, and followed the Cass Review initially with hope, and more recently with a great deal of concern. The Cass Review was established by the UK government and NHS England, supposedly to uncover best practices in healthcare for trans and gender diverse children and young people. There were concerns from the start, with the review choosing to appoint to its leadership a Dr selected for having no knowledge of trans communities, trans children or trans healthcare, and with the review explicitly excluding trans people, including trans clinicians or trans healthcare researchers from the review’s governance body, whilst inviting a number of alleged conversion therapists to be part of their core team. The Cass Final report made a number of extremely dangerous recommendations, amongst them severe restrictions on access to puberty blockers, with no current route to any adolescents accessing them on the NHS. It also cautioned against social transition, particularly in childhood, recommended that clinicians and psychologists be involved before any support or affirmation for a trans child. These recommendations have raised significant concerns and fears amongst those of us who understand the existing literature on trans children, and for those of us who have personal experience of being trans or supporting a trans child.

Since the publication of the Cass Final report I have been approached by concerned trans young people, by concerned parents, and by erstwhile allies, asking the same three questions, questions that I want to speak on today. People have been asking me: Does the evidence show that social transition has more harms than benefits for trans children? Does the evidence show that puberty blockers have more harms than benefits for trans children? Does the evidence justify current restrictions on both social transition and puberty blockers? For those of you who only want to listen for one minute more I will summarise: The evidence shows clear benefits of puberty blockers and no significant harms – they are recognised as safe and effective in blocking puberty, and are still today recommended with no controversy when used by cis children. The evidence shows clear benefits of social transition and zero recorded harms. The evidence in no way justifies the current restrictions on either social transition or puberty blockers.

For those of you who are interested in listening for a bit longer, I will in the next 15 or so minutes delve into the evidence base and the Cass Review approach to evidence, revealing the manipulations or sleights of hard used to justify current policy restrictions. I will start with the topic of social transition. The Cass Review’s approach to social transition can be regarded as a perfect example of a healthcare service being impacted by anti-trans bias. Instead of the evidence-based policy making it claims to deliver, it is an exemplar of prejudice driven evidence. I will here cover this topic in five sections.

Section 1: Appraising modern evidence

Firstly, we can consider the Cass Review’s approach to disregarding existing evidence on social transition. 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, and 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.

Let’s take one study as an example to see what York has done in its systematic literature review. Let’s look at a 2016 study by Kristina Olson from the USA. This study followed 73 socially transitioned trans children from the US and Canada. The research was considered ground-breaking at the time of publication, back in 2016. It found that trans children who were supported and able to socially transition in childhood, had positive levels of mental health, depression and anxiety, levels of mental health similar to their cis peers. This was in direct contrast to research at the same time from populations of trans children and adolescents who had not been supported to socially transition, where high levels of depression, anxiety, suicidal ideation or suicide attempts were common. This ground-breaking finding that supported trans children have good levels of mental health is reported by the York systematic review thus “The study found no significant difference in depressive symptoms compared with population averages”. Do you see how the study’s own findings have been distorted to make it sound as though the study result is inconclusive?

The York systematic review fails to analyse and summarise the substance of the findings and conclusions of the existing literature. By contrast, within my own peer reviewed scoping study on social transition I synthesise all the recorded benefits and harms within the current literature. Positive outcomes are noted across a broad range of domains: Social transition is associated with positive mental health, reduced depression and anxiety, reduced suicidal ideation, increased happiness, improved school attendance, improved educational attainment. These potential benefits are noted across a range of study types. These benefits are especially emphasised in any studies that actually spoke to trans children or their families about their experiences. However, all studies that actually spoke to trans children and families are disregarded by the Cass Review as being ‘low quality’.

The systematic review claims to undertake an assessment of study rigour, representativeness or quality, utilising this assessment to devalue the studies that listened to trans children or families. Bizarrely they adopt a definition of social transition that is in no way standard, including children who only change appearance or clothing, in order to justify inclusion of a 2013 study in which no youth actually socially transitioned according to today’s understanding of this term. Their quality assessment criteria, which are not well explained and were completely invented by the York team, enable them to assess studies such as the 2016 Olson study as low quality, scoring 1.5 out of 5 for quality. The Olson study is downrated because the children in the sample were not representative of all trans children, because their families were willing to support a trans children whilst many are not. It was downrated because it did not include a control group of the same trans children who were denied social transition throughout childhood just to improve study rigour. This study took data from a community sample, and within a community sample it is obviously not within the researcher’s control to create a control group of the same children who are forcibly denied affirmation for years at a time. There are huge ethical problems in suggesting it should be possible to create a control group of trans children who equally want social transition but are denied it for years on end. The fact that some clinical centres have ambitions for such a study raises serious concerns about clinical control and abuse over trans children in the name of research. There’s another quality factor, ‘reliability of ascertainment of social transition’. It is not defined or explained. The Olson study does not pass this criteria, whatever it means. The Steensma study from 2013, the one that the York team had to redefine social transition in order to include a study that only focused on children who had changed their clothes or hair, is rated as the second highest quality. There is significant massaging of the criteria for quality in order to devalue the evidence base that most strongly supports the benefits of social transition. The York approach to quality assessment does not require studies to have actually spoke to the subjects of the research.

In a field where there is a small population, and a limited body of current literature, we have to question what is the most appropriate approach to reviewing the literature. Should we review all the literature to see what benefits and harms can be found and take the best possible decisions based on existing evidence whilst highlighting future research priorities? Or should we critique the quality of existing literature, rule it of insufficient quality, rule it therefore inconsequential, and then proceed to policy making with no consideration of the existing evidence base. This is the York and Cass approach.

Social transition in trans children is a step initiated by a trans child. Usually in the face of substantial opposition and delays by all those around that child. When a trans child asks to be seen as who they are, asks to be shown acceptance and love and support, a trans-positive parent would respond with love and acceptance unless there is a clear reason to do otherwise. The Cass Review surely has some significant evidence of potential harms of a social transition, in order to justify caution or restrictions. Surely there is some evidence of harm to counter the existing evidence base of benefits.

Across all existing studies the results are either extremely positive on the benefits of social transition (15 studies report significant benefits), or are neutral on the topic (2 clinical studies reported neither positive nor negative impacts – these studies have methodological limitations linked to not speaking to the subjects of their research). Within all of the existing literature there are no example of harm caused by social transition. Zero. Let me repeat that – there are zero examples of harms of social transition in the current literature.

How, you might ask, does the Cass Review move from an existing body of literature that is predominantly extremely positive on social transition (with two studies that are neutral) and no evidence at all of harm across any of the literature, to a policy position cautioning or restricting social transition?

There are three steps in this sleight of hand.

Step 1: As explained earlier, critique the existing literature as low quality, using the systematic review to claim that we no nothing on this topic with any certainty.

Step 2: Create a (completely unevidenced) potential harm, to counter the known benefits of social transition.

Step 3: Argue that this (fabricated) harm in Step 2 justifies restrictions on social transition until the time when the evidence of benefits is rigorous, high quality and certain.

Let’s look at step 2 and 3 in turn.

In step 2 the Cass Review and the associated York systematic review article makes a claim that social transition may change the outcome or trajectory for trans children. The word may is doing extremely heavy lifting here. They speculate that, perhaps we should be concerned when socially transitioned trans children grow into trans adolescents and trans adults. Perhaps, say those opposed to trans existence, it is the social transition (rather than them being trans) that makes them continue as trans. The Cass review speculates that perhaps, these children become ‘stuck’ as trans, cemented into a trans existence. What horror.

The Cass approach disregards the claim that ‘social transition is good for mental health and happiness’ as insufficiently evidenced. Cass doesn’t even consider the idea that trans kids have a right to self-actualisation.

At the end of last week Cass released some follow up clarifications, trying to disrupt trans community criticisms that the Cass report is biased and intentional devised to deny trans rights and trans healthcare. In this clarification, Cass repeats the assertion that the literature on social transition is inconclusive. The existing evidence, that shows a host of benefits and zero harms, is not rigorous enough, according to Cass to merit any conclusions whatsoever. In the very next sentence Dr Cass states, with utter authority and confidence, that the majority of trans kids will stop being trans at puberty, especially if denied social transition.

The Cass report presents the theory that social transition may change a trajectory, and cement trans kids into a trans existence. This claim is upheld with literally zero evidence. Zero. A trans-positive policy position (that social transition is beneficial) is rejected outright, described as completely unevidenced. A very much weaker claim used to justify restrictions is presented authoritatively as though settled fact. These double standards are a feature across the Cass Review. It is prejudice-drive evidence, prejudice-driven policy. 

Let’s look at the evidence for the claim that social transition may change trajectory. In attempting to justify this claim the Cass Review looks to some really old studies, and makes some really wildly inappropriate leaps of faith, which we’ll investigate in section 2.

Section 2: A shift in trajectory

The key evidence cited to justify the theory that trans children are having their trajectory changed by social transition is a 2016 literature review by Ristori and Steensma. This same 2016 literature review is also used to justify the same theory that puberty blockers are ‘changing the outcome’ and cementing trans children of today into trans identities into adolescence and adulthood. If only we went back to the approaches of last century, with widespread denial of social transition and puberty blockers, then we could stop trans children from growing up as transgender. The fact that this 2016 literature review takes such a prominent place in justifying the policy recommendations of the 2024 Cass review demonstrates how far they need to stretch to justify their policy preferences.

The 2016 literature review has been widely criticised since publication. It has long been the document that anti-trans advocates in the UK have relied upon to justify restrictions on trans children’s lives and healthcare. I critiqued this very article in depth in 2017 in my blog growinguptransgender. I was not surprised to see the same 2016 literature review taking a central place in legitimising Cass policy recommendations in 2024. It provides a rather complex and hard to critique cover for anti-trans policy recommendations. It is also inaccessible, being a publication that is not open access and cannot be read by most. This literature review includes studies like the 1968 article “Deviant gender-role behavior in children: Relation to homosexuality’, the 1984 article the Early effeminate behavior in boys. Outcome and significance for homosexuality. The 1985 article ‘Extreme boyhood femininity: Isolated behavior or pervasive disorder?’ The 1987 article “The ‘sissy boy syndrome’ and the development of homosexuality”. This is the literature the 2024 Cass Review is looking to.

The 2016 literature review looks at gender clinic studies, or studies on gender non-conforming children, from the 1950s to the early 2000s. Across these studies it reports a very low portion of gender clinic kids being trans in adolescence or adulthood. Apparently in the 1950s, 1960s, 1970s, 1980s, 1990s, 2000s, gender clinics did something that ensured only a minority of kids ended up as trans. Whereas now in 2024, the majority of kids in gender clinics are recorded as trans into adolescence and adulthood. For the Cass Review, this so called ‘shift’ from a minority of gender clinic kids growing up as trans to now a majority is very significant, and worrying. This is the silver bullet of supposed ‘harm’ that the Cass Review uses to justify authoritarian restrictions (or caution) on social transition. What if, they claim, it is the social transition that has changed the outcome? Or the puberty blocker? Or both? What if we moved back to the approaches of the 1950s or 1980s (when apparently there were no trans teenagers or adults), where a majority were ‘cured’ in early childhood. Could we save innocent children from a terrible future of being trans?

This is literally the principle argument upon which the Cass Review bases its opposition to both social transition and puberty blockers. And the 2016 Ristori and Steensma literature review is the key citation to substantiate this theory.

Section 3: Puberty blockers

There are two important questions when reviewing evidence on puberty blockers. Question one, are they effective? The evidence is very clear that puberty blockers are effective at blocking puberty. This has never been in doubt. Despite incontrovertible evidence that they are effective at their primary purpose, stopping puberty, the Cass Review puts doubt on the evidence by shifting the goal posts. Instead of asking, are they effective at stopping puberty, and therefore useful for youth who wish to stop puberty, the Cass Review asks a different question. They ask, are puberty blockers effective in ‘treating gender dysphoria’. You will be shook, dear listeners, when I tell you that the Cass Review manages to wrangle the literature review in order to claim that there is insufficient evidence that puberty blockers ‘treat gender dysphoria’.

The second important question on puberty blockers is this. Are they safe? This question again is incontrovertible, if you guard yourself against anti-trans bias. Puberty blockers are categorically safe. The exact same medication is used in the NHS today with zero controversy or concern, as long as it is used for stopping the puberty of cis kids. Evidence of its safety when used to stop puberty is ignored by the Cass Review manipulating the goal posts. Safe use for cis kids is evidenced as safe for ‘treating precocious puberty’, but not evidenced for ‘treating gender dysphoria’. The exact same medication, for the exact same reason (pausing puberty), is somehow less safe for treating trans kids. There are not any actual arguments for a claim that puberty blockers are unsafe. There are some minor side-effects, as with any medication, that can be monitored and managed. Blocking puberty delays the increase of bone density that comes with pubertal sex hormones, that can be important for supporting growing bodies. This needs to be monitored, and youth shouldn’t be without sex hormones for too many years, this is a standard part of individualised healthcare. In place of any actual evidence of harms of puberty blockers, and alongside a body of ‘low quality’ evidence of benefits, the Cass Review bases its opposition to puberty blockers on this same claim. The primary argument against the use of puberty blockers for trans kids is the hypothesis that puberty blockers, as with social transition, may change the trajectory and outcome, cementing kids into continued existence as trans when perhaps a lack of social transition, and being forced through endogenous puberty would be just what is needed to make them cis.

Let’s put aside some obvious conceptual and ethical flaws for one minute, and focus on the evidence supporting the claim that there are now kids growing up as trans who might have ended up as cis if those around them had adopting a more restrictive approach. The only evidence for this claim that puberty blockers may change outcomes is the very same 2016 literature review, that supposedly proves beyond a shadow of doubt that trans kids are being cemented into a trans identity by having social support or puberty blockers. We need to look at this 2016 literature review.

Part 4: Older gender clinics

The 2016 literature review by Ristoria and Steensma is cited to claim that a minority of trans kids in the 1950s-2000s grew up as trans adolescents and adults. To claim that something negative and worrying has happened to change the outcome. We need to look at this literature review, and its associated literature, and ask, has there indeed been a meaningful shift in trajectories? Are too many children staying as trans into adolescence? Are gender clinics no longer being successful in curing trans children? 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 effort 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 think. 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 – gayness in women was perhaps less of a challenge to the social order, and in any case women were more easily socially, legally and financially controlled at that time. Theorists of the 1950s and 1960s didn’t properly understand or care about the distinction between gay and trans. Infact being trans was seen as a more extreme case of the same disorder, a gender identity disorder that went from being proto-gay or a bit gay, through to very gay, through to trans. It was hoped that if you intervened in childhood at the point of being proto-gay or a bit gay, you could stop the progression through to very gay or even worse, to trans.

Being a bit gay in childhood was not related to sexual or romantic attraction. Instead a long list of factors that were ‘a bit gay’ were highlighted as being risk factors for a dangerous journey towards actual gayness or transness. These risk factors in young boys included showing emotion, being bad at sports, sitting in an unmanly posture, being friends with girls, playing with girls toys, not playing with guns, liking your mother. In misogynistic gender clinics from the 1950s, 60s, 70s, 80s, 90s and 2000s, a very big focus was placed on blaming mothers. Mothers were to blame for permitting their sons to show emotion, for not punishing them for gentleness, for showing their sons too much kindness. Gender clinics had projects in the 1980s literally titled ‘the sissy boy project’. Boys who were considered proto-gay were punished and shamed for being insufficiently masculine.

A man called Karl Bryant was one of the key children tortured and harmed in the ‘sissy boy’ research project. In adulthood he wrote a PhD on his experiences, work that has been one of the most significant influences on my own work. He was never a trans child, he was a cis boy who was deemed by gender clinicians to be unacceptably unmanly. He wrote about the harm and trauma of his experiences in gender clinics in the 1980s, of the shame of feeling that who he was was at some deep level, unacceptable to those he loved the most. Karl Bryant did not grow up to be a trans woman, but he was never studied and researched for being a trans child. Yet this exact study is one of those included in the 2016 literature review, and relied upon by Cass to justify the claim that it is social transition or puberty blockers that is causing today’s gender clinic children to be locked in to a trans identity.

Gender clinics of the 1950s-1980s were not filled with trans children as they are today. They were filled with the kids, almost all boys, whose parents feared they might grow up gay. They were the kids deemed unacceptable for having emotions, for being friends with girls, for being gentle, or being close with their mothers. A vast majority of these children, problematised for their non-conformity, did not grow up to be trans women. But they were also not trans children. They are a substantively different cohort. This will not be a revelation to the Cass team. They are aware of this criticism of the older literature – but this criticism is pushed to the side, because this theory is the only justification they can find for the policy recommendations they wish to endorse.

In the gender clinics of the 1950s and 1960s, the treatment goal of such clinics was overtly to prevent homosexuality. In the 1970s and 1980s, 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 with your mother were instead rebranded as ‘gender identity disorder’. Being trans was not part of the diagnosis utilised by gender clinics until after 2013. Before 2013, gender clinics diagnosed and problematised mainly boys for gender non-conformity, including predominantly cis boys. The fact that a large majority of the children being studied and probed for gender non-conformity in the 1950s-1980s 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’ key objection to both social transition and puberty blockers.

The handful of studies from the 1990s and early 2000s looked at a more mixed cohort, with more trans children being researched and probed in their treatment arms (treatment involved hiding girly toys and telling mothers to stop hugging their children to make them toughen up). As more families grew in acceptance of the idea of a child growing up to be gay, the cohort of children whose families took them to have their behaviour analysed or fixed at a gender clinic grew to include more trans girls. Trans boys and gender non-conforming cis girls were more rare in gender clinics at that time, when the biggest concern was on problematic femininity.

 The later studies of the 1990s and early 2000s already show a significant shift in the portion of children who are classified as identifying as trans in adolescence or adulthood. This shift did not speak to a change in outcome, but a change in those being seen in the clinic, with a reduction in children being problematised for the worry that they could end up as gay. If you read these studies closely, the authors have some clear insights. Steensma, for example, writes that there is a significant difference amongst the cohort being seen in gender clinics at that time. He writes that there are a portion of children, who are distressed at the idea of puberty, and express a desire to socially transition (social transition in childhood was not supported by clinics in that period). This portion, the portion who is distressed by puberty and wants to transition, you might presume, are trans. Another portion of the children in their clinic, are not distressed at the idea of puberty, do not wish to transition. This portion, you might presume, are not trans. How these children actually identify, we do not know. The study authors did not bother to ask the children under their care. The researcher’s focus was not on identity, but on problematising childhood gender non-conformity and trying to work out which ones would end up gay or trans into adulthood. The very work, including research by Steensma, is used by Cass to justify a claim that the very process of going through puberty will resolve gender identity related distress in the majority of cases – to make a trans child cis. Yet even that very study is very clear that there are two groups, one who is distressed at the idea of puberty, and another group who is not. Even this older research by Steensma absolutely does not show that forcing a trans child who is distressed about puberty through endogenous puberty will make that child cis. 

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 1990s 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.

Part 5: Ethics and Eugenics

I want to end with some thoughts on ethics. The Cass Review has shown zero evidence of harms of social transition or puberty blockers. The only harm is this hypothesis that they change the trajectory and outcome, locking children into a trans lifetime. This hypothesis is based on the worst quality evidence I’ve ever seen. This is why trans healthcare researchers are feeling stress and dismay at UK media and politicians cheering on Cass’ evidence-based policy. It is a major exercise in gaslighting.

But let’s also unpack the main ‘concern’ or risk proposed by Cass to justify restrictions on trans children. Why is growing up and still being trans seen as a problem?

Here is where the Cass Review reveals its biases.

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.

The Cass Review does not look at the existing evidence of the harms of authoritarian and abusive restrictions on trans children. It does not look at the harms of requiring children to be assessed and problematised by gender service clinicians before showing them acceptance and love. It is not interested in this type of evidence. My own research has looked at the harms experienced by trans children of all ages in abusive, intrusive and coercive gender clinics. My own research has looked at the harms that parents noticed when they delayed their own child’s social transition for months and years, often on the advice of gender clinicians. These parents talked about seeing rising levels of anxiety and depression in their children. Of suicidal ideation and suicide attempts. They talked about a loss of childhood joy, and children losing happiness, self-confidence and hope in the future. Research undertaken with trans adults on their childhood experiences shows the harms of childhood rejection and childhood conversion therapy, the risk of children growing up ashamed of who they are. The Cass Review does not look at this evidence. Indeed the Cass Review is not interested in hearing from trans professionals, trans researchers, trans adults or trans children. We are not seen as trusted authorities on our own lives. We are not seen as reliable witness.

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.

The whole Cass Review process is a manifestation of cis-supremacy. Of cis power over trans communities and trans children. Cis people hold all the power. They set the rules of the game. They dismiss existing evidence of benefits as ‘low quality’, whilst at the exact same time endorsing policy recommendations built on an absolute shambles of distortion, misrepresentation and nonsense. They do this in the knowledge that they will get away with it, because trans voices are disgregarded and dismissed.

Trans people and particularly trans children are deeply harmed by the cis-supremacist NHS. We need to loudly call out the whole process as a sham, engineered to legitimise abusive and eugenicist measures that are already causing acute harm. We need to recognise that trans children have rights, including the right to a happy and supported childhood. Trans children have rights including a right to affirmative healthcare without pathologisation. We need to stand with trans children and demand that their rights are respected.

We have an uphill struggle ahead of us. But we need to stand together and demand better for all trans children. Trans rights. Trans power. Trans happiness matters.

Literature mentioned above:

My peer-reviewed scoping study of all current literature on social transition:

C, Horton (2024) The importance of child voice in trans health research: a critical review of research on social transition and well-being in trans children. International Journal of Transgender Health, 1-18

My published research on trans children’s experiences with social transition, gender clinics and puberty blockers (none of which is acknowledged anywhere in Cass report) can be found here:

My peer reviewed critique of the Cass approach:

Horton, C. (2024) The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children. International Journal of Transgender Health, 1-25

Other referenced studies:

Ristori and Steensma (2016) Gender dysphoria in childhood. Int Rev Psychiatry 28(1):13-20. (This article is not open access, but on the above link you can click on references and see the references this literature review relies upon. I critiqued this review back in 2017 here: Since this blog was written in 2017 the evidence of benefits of social transition has continued to grow (see 2024 scoping review above). The evidence against social transition has not grown, it relies upon this same 2016 literature review.

The Cass commissioned York systematic review on social transition: Hall et al (2024) Impact of social transition in relation to gender for children and adolescents: a systematic review. Archives of Disease in Childhood.