Two New Papers on Qualitative Research Not Included In Cass

Two papers published in December 2024 and January 2025 as open articles delve into narrative accounts discussing trans health care for adolescents and young adults. These papers are based on research commissioned by the Cass Review, but which were conducted independently of it, over a period between March 2022 and December 2023. Both papers were authored by Dr. Christine Jackson-Tyler, research associate, and Dr. Karl Atkin, professor, both at the Department of Sociology of University of York. These authors have also summarized their other independently commissioned work for the Cass Review in Appendix 3 of the Review.

The two papers are entitled “Negotiated care practices: The experiences of young people who question their gender, their parents and the healthcare professionals who support them” (published in Social Science & Medicine, January 2025) and “Negotiating Care: The Biographical Narratives of Young Adults Who Questioned Their Gender When Younger” (published in Sociology of Health & Illness, December 2024). The former, per the title, analyses interviews performed with 14 youth aged 12-18, reached through GIDS and other organizations, as well as 12 parents, not all of whom are supportive of their children’s desire to seek care. The researchers also talked with 23 clinicians, the majority of whom worked at GIDS, about their experience. The latter paper followed a similar approach of analyzing interviews done with 18 young adults aged 18-30. Both papers sought to represent a variety of identities, views, and outcomes, and to do so with an eye to examining the relationship between the carer (clinicians and clinics) and the cared-for (patients, but, in the case of trans youth, the parents as well) and how the dynamics of identity exploration can be influenced by the systems put into place to aid  youth and young adults in their journey.

We would like to address one issue at the outset. Both papers feature the phrase “XXX Who Question Their Gender” in their titles, and throughout the papers the phrase “gender questioning” is used, albeit occasionally with the qualifier “trans and gender questioning”. WTT has reached out to the authors about this phrasing, as it is not defined within the papers. Dr. Atkin responded in an e-mail that they are aware of the sensitivity regarding language, but also that there is little consensus on terminology. Inclusiveness of language was stressed by those involved with the research, including interviewees. The term “gender questioning” was deemed acceptable by them, and was also found to be in use by organizations such as Gendered Intelligence and Mermaids. To use phrases such as “trans youth” could have resulted in forcing a label on those who either did not desire it or did not feel it reflected them and their experiences. In addition to reflecting a wide range of experiences, “[w]e also wanted to avoid using medicalised terms such as gender dysphoria or distress” as this was not seen by participants as being reflective of their experience (see the summaries below). They also noted that, “Sadly – and irrespective of these important debates about terminology – the paper demonstrates considerable disadvantage and discrimination, in which those we spoke to struggled to gain access to appropriate care.”

WTT has looked into the usage of the term “gender questioning” on the Gendered Intelligence and Mermaids UK websites. At a glance, many of the usages were in the form of “trans, non-binary, and gender questioning” or similar, as opposed to “gender questioning” alone. Both websites also had resources describing their terms. Gendered Intelligence in their  Trans Inclusion at Work Policy Glossary define “gender questioning” as  “exploring your gender with a view to understanding it more fully”. Mermaids in their Gender Identity Guide similarly defines “questioning” as “The process of exploring your own sexual orientation and/or gender identity”. 

In possible relation to this, some issues are pointed out with regards to the Cass Review itself in the trans youth paper. The Review was noted as seeing the current gatekeeping role that GIDS fulfilled for medical pathways beyond psychotherapy as being too permissive. In addition, publication of the Cass Review’s interim report during the period of study also was said to have impacted participation by interviewees. From our perspective at WTT, these both speak to a possible chilling effect the Review may be having on performing the very research that the Review calls for.

Let’s move on to looking at the papers themselves. They both show broad similarities in the experiences of youths and young adults, so we will begin there. Direct quotes from the papers are made within double quotations. Observations by WTT are added in parentheses outside of quotations. Discussions and quotes regarding youth, parents, and clinicians refer to “Negotiated care practices…” and young adults to “Negotiating Care…”.

Patients and Their Experiences

Seeking care for trans youth often began with parents seeking care for them, but these experiences often began poorly. One youth was quoted as saying, “Well, my GP was actually quite blunt and said, ‘What you’re going through is just a phase.’ […] Who just ignored what I said and thought I’d grow out of it.” Waiting times in excess of three years also led some to believe they were being made to wait while others who were “more trans” than them were seen first, creating anxiety and self-doubt.

For both youth and young adults, getting a diagnosis of gender incongruence or gender dysphoria could be simultaneously legitimizing as well as marginalizing. While diagnosis provided reassurance and justification for seeking care, it also led to young adults feeling they needed to present in a stereotypical binary fashion in order to convince clinicians of their needs. Even so, the diagnosis was recognized as being important for accessing care, even while patients knew it wasn’t the diagnosis that made them who they are. At the same time, diagnosis was seen by some with suspicion, as though it was only through this kind of labeling that they could be seen as being legitimate, and that it was a form of “inappropriate gatekeeping”. Trans youth in particular were sensitive “to possible accusations that they only begin gender questioning, once they discover different expressions of gender,” but emphasized the fact that questioning came first.

Both groups found that understanding the diversity of the LGBTQIA spectrum allowed them to find ways to label and understand their experience. Trans youth noted that “(n)aming does not create (their experiences).” (This of course runs contrary to popular narratives of how exposure to information on LGBTQIA people may somehow cause someone to become trans.) This also led to patients in both groups coming to understand the variety of ways to transition that exist, even beyond the binary. They expect their gender identity to be respected even as they are open to exploring it. Young adults saw it as “an act of agency that enables them to pursue opportunities, consistent with their values” while being explicit that it isn’t a “lifestyle choice (or preference)” nor an “‘adaptable’ identity that can be disregarded from one day-to-the-next.” Young patients expressed a similar sentiment, seeing their identities as “non-negotiable” during the course of therapy.

Both youth and young adults expressed the desire for flexibility in their explorations, especially as their identities may extend outside of the gender binary. Youths seemed to feel that services were generally supportive of this, although they worried that not following “transnormative” narratives of a binary existence with a linear progression would lead to people not taking them seriously. Young adults said they desired a free environment to discuss and explore, but many still felt they needed to “justify their questioning”. They are also aware that because their perception of their identity may become more refined over time, and does not fit neatly into cisnormative notions of gender, that their narratives “can be regarded as untrustworthy, inauthentic and at times, undesirable.”

Two individuals among those the paper on young adults discusses saw themselves as detransitioners. Both went through private providers and, following diagnoses of gender dysphoria, began on medical pathways. Both “spoke about lack of opportunity to talk”, and spoke of how they felt there was a need for “a space for unhurried exploration, in which an individual does not have to anticipate cis or trans-normativity, to resolve embodied distress.” One was clear that she “did not want her experiences to be used to undermine trans identities and deny life-affirming pathways.”

While the paper on young adults focuses solely on patients, the paper on youth patients also includes sections on parents and clinicians, which we will turn to next.

Parents of Young Patients

Parents of young patients, affirming or otherwise, all expressed that they were doing what they felt to be in their child’s best interests. Some parents felt specialist services did not always offer the best solutions, as well as not being sufficiently “affirmative”, with several parents noting that they had been encouraged to “consider options, inconsistent with how they (their child) felt”. 

One parent, Eric, is quoted as saying, “We didn’t feel we could trust them because we felt that […] some of them really didn’t want to believe it and they were actually trying […] to get Logan to desist from it, trying to get him to change his mind. […] That’s quite difficult because, you know, to suggest that you might be wanting to affect or harm your child for your own ends is quite insulting (laughs) so yes, my motivation is just to have a happy, healthy kid.” 

Parents who were less certain about how to proceed viewed medical interventions “with apprehension”, with some avoiding GIDS in favor of private psychological services that would have no medical pathway available for this reason. Some felt it was better to exhaust all other options first, or worried that their child’s identity was the result of neurodiversity or poor mental health. Some were anxious about not being seen as sufficiently supportive of their children, while others were unwilling to accept that what their children were experiencing was anything more than a phase.

Regardless, many parents, like their children, appreciated GIDS for being a place where they could air and discuss concerns. The amount of talking, while frustrating for youth, came as a relief to some parents. 

Even so, some parents expressed frustration with what they felt was a system that desired a clear problem with a clear solution, which wasn’t always aligned with how all parents felt. The need to stand back and allow things to progress was noted as being emotionally taxing for some.

Clinicians and Their View of Their Work

Clinicians expressed a desire to create a space for exploration as well as challenging assumptions, especially when patients or parents came with fixed expectations of care. They acknowledged that a diagnosis of dysphoria was “necessary to facilitate access to care”, but were clear they saw youths’ identities as existing independently of it. They also recognized that their place in treatment was potentially contradictory: offering support, while also gatekeeping medical pathways.

They noted the issues with using standardized decision making tools not matching the inherent complexities of care. Going further, they expressed concern over how care is “becoming regarded as a hazard, which needs to be rendered safe, by subordinating it to a “reductive” and “deterministic” heuristic.” One psychologist notes that “It feels like my role is to protect the Trust […] and show that the service is functioning in ways that it has to.”

Clinicians realize that their approach “may be regarded as exploratory and to some extent cautious,” while maintaining such an approach can also be affirming. They emphasized that exploration can help bring recognition to the possibilities of non-binary identities, in addition to bringing clarity to the patient’s sexuality. This is all seen as helping in making decisions on further care.

They also expressed frustration over how they felt their work is misrepresented, especially in regards to how the complexities of their work can be discounted. 

The paper notes that “many are keen to disrupt current terminology”, noting that one psychologist “with almost a decade of experience” discussed how affirmative models “are effectively informed consent models where people when they enter a service would be given access to endocrine or medical treatments at a fairly early stage” while noting that this isn’t what is happening at GIDS, given that it can take four and a half years to access endocrinology treatments. (We should note here that this is not how affirming care is defined elsewhere.)

Another clinician, a team leader “with a background in child and adolescent mental health”, noted that they were “not invested in any particular outcome.”

Clinicians recognized that taking a slower approach could be seen as denial of care, but emphasized that patients should always be allowed to reflect on and reinterpret their experience.

This concludes our summary of the papers. We will now turn to how they appear to contrast with the Cass Review.

In Contrast to the Cass Review

Both papers demonstrate that the youths and young adults they interviewed are not “simply confused” or subject to some form of “social contagion”, but rather came to services from a genuine desire to receive care. Both groups were apparently dubious of medical diagnoses, but in the end saw it as a useful tool for accessing care, in addition to establishing a common language with care providers. Neither group appears to have seen their identities as being contingent on a diagnosis. Once in a position to receive care, they expressed an appreciation of having an open and accepting space to both discuss and explore what their identity meant or could mean to them. While they may have explored, they were also clear that their identities were “non-negotiable”. This, it should be noted, is different from forms of therapy that may seek to maneuver the patient away from their identity, otherwise known as conversion therapy.

The concept of exploration appears to be taken by the Review to mean that it could lead patients away from being trans. This would, of course, be one potential outcome, but if therapy is truly meant to be an exploration by the patient of themself and their identity, then the conclusion should also be arrived at by the patient. This is clearly different from a therapist intentionally guiding a patient to a conclusion decided on by a therapist. However, the Review uses the fact that such outcomes could exist to speak out against efforts to ban conversion therapy.

The fact that patients saw their identities as “non-negotiable” also stands in contrast to the Review, where the co-occurrence of gender dysphoria with of neurodivergence and other conditions in people presenting to clinics is noted repeatedly, leading to the inference that the Review sees a causal link between the two, similar to some of the parents of young patients that were interviewed. (See the Yale Law School white paper on the Cass Review for more information.) The implication is that, even among the small number of patients who were able to access services, a significant number of them were not actually trans, but merely exhibiting a comorbidity with a possible causal link. These interviews indicate a significantly different reality.