Reflections on the Cass Report

The Cass Report has confirmed that we now have all the evidence we need to show that these irreversible interventions should not be offered in hospitals, nor should they be publicly funded.

“This is an area of remarkably weak evidence, and yet results of studies are exaggerated or misrepresented by people on all sides of the debate to support their viewpoint. The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.”

Following four years of careful study of roughly 9000 children who received treatment at the Gender Identity Development Services at the Tavistock in London, the Cass Report is finally finished. The independent review of data came to the same conclusion as every other independent review: there is insufficient evidence to justify the use of medical interventions for the treatment of gender dysphoria. 

When we think of Bertrand Russell’s china teapot circling the earth we realise that these invasive and irreversible treatments should be proven to help – the burden of proof lies upon the policies that recommend these radical, life-altering treatments and the burden of disproof should not be placed upon those who favour the already well-researched and established least-invasive-first approach.  

In many ways, the focus on ROGD has inadvertently confused an already complicated issue. Transsexualism was accepted as a fringe, vanishingly rare intervention that was carefully supervised by doctors and only available to people with chronic gender dysphoria. Few people were interested in this subject and so the research was always lacking. However the sudden rise in the numbers of children and young people seeking medical transition (typically having previously show no sign of gender nonconformity), led to a corresponding rise in the number of scholars studying this phenomenon. And what has emerged is that there is no quality research available to support the medicalisation of a person’s sense of identity.

While people are free to engage in extreme body modification once they are fully informed of the many related risks and complications that are likely to happen as a result of these interventions, yet it must also be acknowledged that it is only extremely mentally ill people who seek these dangerous interventions. Further, there is no justification for these interventions to be publicly funded, nor should they be offered in hospitals. There is already precedence for this – cosmetic clinics already offer body modifications and their clients pay for these services out of their own pocket.

How far does the duty of care go in terms of protecting mentally ill people from being self-destructive? This is a difficult quandary and there is plenty more discourse needed on this subject. Should an anorexic person have the right to refuse a feeding tube when the medics belief it is a life-saving intervention? Do surgeons have a moral duty of care to refuse the hundredth cosmetic surgery on a person with the knowledge that these interventions cause more harm than good?

The burden upon society must also be considered. Prior to the last decade or so, most people could tell if a person had medically transitioned, and the numbers were so small the imposition on society was minimal. This is no longer the case. Testosterone is a very powerful hormone and female-to-male transition is often very convincing. Advances in medical technology have created a situation where, for the first time in history, a person’s sex is no longer public knowledge. Our height is public knowledge; our appearance is public knowledge; our stage of human development from baby to child to adolescent to young adult to adult to elderly person is pretty much public knowledge; however these days we cannot presume a person’s sex. The impact of the removal of this public knowledge about others has not really been studied and so, just like medical interventions for gender dysphoria, we are building the aeroplane while it is flying in the air.

The entire concept of medicalising the body because of an unsupported and impossible theory that a person can be born in the wrong body has been drawn into question as a consequence of the recent Cass Report as well as other recent systematic reviews; for example the two systematic reviews on puberty blockers and on cross-sex hormones by the British National Institute for Clinical Excellence (NICE) from 2020 that demonstrated there is no clear clinical benefit pertaining to these medical treatments.

In therapy there is a well-known phrase that ‘you can build evidence forever’. When a patient is continuously building evidence without acting, it is the role of the therapist to gently point out that the patient may have enough evidence – they don’t need to continue to gather, sometimes the accumulation acts as a distraction, and perhaps the time has come to act. We have now reached this stage in the accumulation of research about irreversible interventions for medical transition. We don’t need any more evidence – everyone working in this field knows that the results of any future research will suggest that there is no quality evidence to support these interventions.

The myth of suicidality among this cohort has been well and truly quashed. Michael Biggs’ work in this field showed that over a period of ten years (between 2010 and 2020) there were four known or suspected suicides among fifteen thousand children and adolescents on the GIDS waiting list. Two of these suicides were receiving treatment, two were on the waiting list. Every suicide is a tragedy however these numbers align with the risks associated with other mental health challenges. Additionally, the numbers of suicide post medical transition are worryingly high. A long-term study from 2011 shows that people who medically transition are more than 19 times more likely to die by suicide compared to the general population.

Extreme body modification might create a bump in satisfaction initially, but the subsequent disappointment as the months turn to years can be devastating. Those who promise to care for the ill need to contemplate the impact of colluding in false hopes and unrealistic optimism with a distressed patient who will one day (usually long after their last appointment with the surgeon) inevitably confront the cold hard reality of life; we might be able to change our external bodies but we can never change our sex.

The move from ‘first do no harm’ to ‘buyer beware’ comes with many risks for society. Doctors are not shopkeepers simply doling out whatever prescription the patient requests. This is a position that comes with considerable responsibility and doctors are both well-trained and well-paid for this. Mentally ill people need quality care that is responsible, thoughtful and cautious, it is irresponsible to offer them consumer-led, speedy and irreversible medical interventions.

Doctors who carry out irreversible interventions on highly vulnerable, profoundly distressed people need to consider their responsibilities in this context. Policy-makers need to reflect on their part in the play. 

Meanwhile it is a fool’s errand for researchers to continue to try to research empirically unfalsifiable claims. The burden of disproof should not be on clinicians who operate within the bounds of conventional, evidence-based medicine and therapy. The burden of proof is now on the policy-makers and the professionals upholding and carrying out these radical, life-altering interventions.