Last week, the final report from the Cass Review was published. At NSUN we stand in solidarity with trans people, and with the trans-led organisations who have so far responded to the report to express their concerns, including about how the review was conducted, its recommendations, and the impact it will have on care for transgender people. Below, we outline key issues with the report and express our own concerns relating to the mental health context.
A key argument in the report is that we should be offering mental health support before medical care for trans people. While everyone deserves access to proper mental health care, there are multiple issues with this position. Firstly, the report can be read as positioning transness as a mental health problem, justifying delays in medical care and undermining trans people’s autonomy by suggesting that what they need are opportunities to “rethink” their identities. Secondly, in its emphasis on the role of psychological therapies in trans healthcare, the report misses fundamental flaws in the current mental health system, including the barriers and harms that trans people face when trying to access mental health support.
The report must (and will) be interpreted within the current political climate. Trans people are regularly and cruelly used as pawns in a culture war, with the UK becoming an increasingly hostile place for trans people. In this context, the Cass Review could serve to bolster and legitimise transphobic and trans-hostile campaigning within the UK, interpreted as “evidence” to support anti-trans rhetorics.
About the review
The research, conducted by paediatrician Hiliary Cass, was commissioned by NHS England and NHS Improvement. The purpose of the review was to make recommendations about healthcare provision for transgender youth. The report begins with some promising sentiments, recognising that trans youth need high quality, holistic, personal and timely care. It also emphasises that the NHS should provide appropriate care for all trans people, and calls for better training for NHS staff on how to work sensitively with all trans, non-binary, and gender-questioning young people.
However, concerns have been raised by many groups that the recommendations made by the review limit trans people’s access to the care which the report acknowledges they deserve. Overall, the report appears to ‘advocate [for] no medical interventions before the age of 25, because people may change their minds’. This sentiment treats trans people with hostility and suspicion, and fuels hateful rhetoric from anti-trans campaigners. It may also be used within government and NHS management to justify stripping transgender youth of what can be vital and lifesaving healthcare.
It will be up to NHS England to decide how the report’s recommendations are implemented, but as TransActual have highlighted, NHS England do not have a good track record in this area, including excluding trans people from being part of the Cass Review core team (while advocates of conversion therapies were included), and announcing an effective ban on all puberty blocker prescriptions for trans youth unless recipients agreed to participate in a clinical study into that medication.
Methodological flaws and damaging rhetorics
Regarding methodological flaws within the review, concerns have been raised in detailed responses by trans-led organisations and experts such as the Trans Safety Network and TransActual, by media outlets such as What The Trans, and other groups such as Therapists Against Conversion Therapy and Transphobia. This includes the decision to exclude swathes of evidence from its review, and the exclusion of trans people from the Cass Review core team.
Concerns have also been raised about the connections between the Cass Review and anti-trans groups, for example, that a key researcher on the review worked to promote “gender-exploratory” therapy for trans people under NHS care. Gender-exploratory therapy works to insert delays into transition and resists patient’s preferences for changes of name or pronouns and has been described as a rebranding of conversion therapy.
The report appears to be predicated upon and perpetuates damaging rhetorics around transgender people, especially trans youth. The research claims to be responding to “rising” numbers of transgender youth, with the implication that trans youth are the result of trends or fads relating to gender identity, rather than people who are experts on their own experience and should have a right to access gender-affirming care.
Moreover, the report suggests that trans people should continue to be treated under childrens’ service until the age of 25, on the basis that they are insufficiently able to make key decisions until this age (despite no evidence supporting this claim). This suggests that what young people need is to have time to think and reconsider their transness. As Trans Actual have highlighted, this not only undermines the autonomy of trans youth and young adults, but also implies that “waiting” is only successful when the outcome is choosing not to transition.
The mental health context
Overall, the Cass Review advocates for greater restriction on medical transition and a stronger focus on psychological treatment. We fear that mental health is being weaponised in the Cass Review to gaslight trans people and discourage them from transitioning. These arguments also fail to acknowledge the limits to our current mental health system.
The review calls for care that is ‘safe, holistic and effective’ — in the form of an individualised care plan consisting of screening for neurodevelopmental conditions and a mental health assessment — in place of gender-affirming physical care. In doing so, the report cites the NHS’ inability to cope with the current demand for gender services. However, the review fails to extend this acknowledgement to issues of capacity and safety also present in the mental healthcare system.
In emphasising mental health care as the primary response to those who are seeking gender-affirming care, the review fails to acknowledge the chronic underfunding and the structural systems of harm present within mental healthcare, many of which already function to exclude trans and young people. Trans people face additional barriers when seeking both physical and mental health care, often facing stigma and unnecessary questioning of their identities, which can serve to exacerbate their distress.
The review goes further in correlating ‘poor mental health and emotional stress’ among adolescents with the increase of young people presenting with gender dysphoria. By conflating these experiences, the review could be read as suggesting that gender dysphoria or transness is a symptom of mental ill-health, and thus that gender dysphoria could and should be treated or cured through psychological approaches. This is the same logic that underpins conversion therapies and works to pathologise trans identities, rather than considering mental ill-health within the trans community as a symptom of societal transphobia and state failure to provide adequate care.
Additionally, the preface to the report states that the review was motivated, in part, by trying to explain the ‘increase of numbers of predominantly young people and young adults who have a trans or gender diverse identity’. In questioning the rise of trans people seeking gender affirming-care, the report undermines the autonomy of trans people and their ability to know their own experiences — treating people’s identities with suspicion and implying that they may be led by something other than their knowing of themselves. It fails to position rises in people seeking gender-affirming care as a potentially good thing, which for many is driven by increased visibility, understanding, and community.
Conclusion
We stand in solidarity with those for whom the publication of this report has caused distress, and we echo calls from trans-led organisations for the findings of the review to be treated with caution. In the context of rising institutional, political, and societal transphobia in the UK, we must be critical of efforts to roll back trans rights and autonomy, pathologise transness, and restrict access to healthcare.
As an organisation led by people with lived experience of mental ill-health, distress, and trauma, we reject efforts to position transness as a mental health problem. Safe and timely access to mental healthcare is essential, but this must not be used to undermine the autonomy of trans people and their position as experts of their own lives. NSUN stands with trans people, and will continue to fight for increased access, choice, and autonomy in medical care.
We want to finish by echoing the concluding words of the Trans Safety Network’s statement:
“We are especially concerned, in light of 4 inquests we are aware of initiated over the last year for young trans people who died by suicide while waiting for gender dysphoria healthcare. Those who are affected most by the decisions that are being made are being ignored and harmed by the ongoing violence of this effort to impose a health establishment order against trans people’s agency rather than in harmony with it. There is an extremely long history of medical violence which informed the disability rights slogan ‘Nothing About Us Without Us’.”