Cass Review Under Fire From The British Medical Association: Will the government listen to the experts?

Mila Edensor assesses the criticism towards the Cass Review in the face of its influence in UK policy decisions. 

Archibald Tuttle, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

On Wednesday the 31st of July, the British Medical Association’s (BMA) council voted in favour of a motion to ‘publicly critique the Cass Review’. This comes following national and international scrutiny regarding the review’s methodologies, as well as negative results following the implementation of some of the recommendations. 

For those unfamiliar, the Cass Review was an inquiry into the state of transgender healthcare commissioned by NHS England in 2020.  An interim report was released in 2022, with the final review being published in 2024. 

“The report distances itself from large quantities of research in the field, seemingly for the sole reason that they justify an ‘affirmative approach’.”

The report has been mired with controversy since its inception; firstly, because it covers a contentious topic, but also because the report distances itself from large quantities of research in the field, seemingly for the sole reason that they justify an ‘affirmative approach’. One such example of this is the devaluation of research that did not use a double blind trial, otherwise known as a Randomised Controlled Trial (RCT). Most research into the provision of hormonal therapies do not use RCT’s because, as an example, this would mean that when testing for puberty blockers, one would be giving some dysphoric participants a placebo. Participants would then of course become aware that they had been given the placebo upon the progression of a distressing puberty - raising ethical concerns as a result. Ultimately, this decision led to 98% of studies that demonstrated a positive outcome for HRT being downgraded, and therefore less weighted in the Cass Review.

So, this criticism from the BMA is particularly relevant given that both Conservative and Labour governments have frequently cited the Cass Review within discussion and legislation surrounding trans people. For instance, in 2022 the UK minister for health, Sajid Javid, cited the interim Cass Report as a key factor in his decision to launch an ‘urgent inquiry’ into transgender care in the UK. Characterising this ‘urgency’, Sajid Javid made parallels between the provision of trangender healthcare and paedophilic ‘grooming gangs’. Furthermore, when shedding doubt as to the authenticity of those experiencing gender dysphoria he was quoted as saying the following: “Is it a genuine case of gender identity dysphoria, or could it be that that individual is suffering from some child sex abuse, for example, or could it be linked to bullying?’. This line of thinking follows closely to the recommendations made in the report, which argue that feelings that are likely a byproduct of dysphoria (eating disorders, depression ect), should instead be considered first, with transition being a last resort. 

Pathologizing suppositions such as these enjoyed an aura of legitimacy derived from the Cass Review. But even in 2022, peer reviews in the British Medical Journal were noting that the report ‘ignores more than two decades of clinical experience in this area as well as existing evidence showing the benefits of these hormonal interventions on the mental health and quality of life of gender diverse young people’. The same article also noted that (Hillary) ‘Cass seems keen to find a way forward that ensures “conceptual agreement” and “shared understanding” across all interested parties, including those who view gender diversity as inherently pathological’. It should be noted here that the pathologization of trans people refers to the practice of treating transgender identities as a form of mental illness, rather than understanding that the existence of trans people is representative of human gender diversity. 

“Despite a litany of criticism surrounding the interim report, the UK government paid little mind, and has continued to refer to the Cass Review within key policy making decisions.”

Despite a litany of criticism surrounding the interim report, the UK government paid little mind, and has continued to refer to the Cass Review within key policy making decisions. In 2024, after the High Court ruled that the Conservative government’s decision to impose an ‘emergency ban’ on puberty blockers was legal, Wes Streeting - the current health minister - said ‘I welcome the court's decision today’ adding, ‘Children's healthcare must be evidence-led’. Dr Cass' review found there was insufficient evidence that puberty blockers are safe and effective for children with gender dysphoria and gender incongruence’. What this statement fails to mention is that the review does not include a single instance where puberty blockers have actually  harmed an individual, rather it simply points out that there is little research on the topic. Furthermore, what is not mentioned within the rhetoric of ‘child-safety’ is that dysphoric children given access to blockers experience superior mental health outcomes as opposed to those who undergo a puberty in misalignment  with their gender identity. 

So, despite the fact that even the Cass Review makes no recommendation for a permanent ban on puberty blockers, this is the legislative path Wes Streeting has chosen to pursue. It therefore becomes increasingly clear that as a cultural object, the review has been understood on an international level as a legitimising tool for transphobic rhetoric and policy. Organisations such as the Heritage Foundation, one of the most influential conservative think tanks in the USA, have used it fruitfully.  A direct quote from their website reads as follows:  ‘Public opinion sides with Mr. Brumley, the Cass Report, and the Independent Women’s Forum. A 2023 survey of Americans found that 55% of respondents said it is “morally wrong” to change your gender.’

In this sense, the British Medical Association’s recent stance against the Cass Review stands as a powerful statement against its use as a source of legitimacy for transphobia. This is further cemented by the fact that the BMA attended meetings with Dr Cass while the review was being written, giving it a particularly authoritative position from which to criticise her work. The BMA calls for a ‘pause to the implementation of the Cass Review’s recommendations’ while in the meantime it also supports the continuation of the provision of trans healthcare. Taken directly from the BMA’s website, here is the full list of demands: 

‘Therefore, this meeting calls of the BMA to:

i. Publicly critique the Cass Review; 

ii. Lobby and work with other relevant organisations and stakeholders to oppose the implementation of the recommendations made by the Cass Review; 

iii. Lobby the Government and NHS in all four nations to ensure continuity in provision of transgender healthcare for patients younger than 18 years old; 

iv. Lobby the Government and NHS in all four nations to ensure continuity in provision of transgender healthcare for patients aged 18 or older; 

v. Publicly state support for transgender people, particularly transgender youth, and provision of prompt access to gender identity services and treatment at all ages; 

vi. Condemn the increasing political transphobia which is ostracising transgender people and discriminating against them by blocking their access to healthcare’

Wes Streeting: Chris McAndrew, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons

“When politicians such as Wes Streeting claim that they are enacting transphobic policy in accordance with ‘evidence led’ care, why is it that some experts are valued above others?”

The BMA is the trade union and professional body for doctors in the UK. So, when politicians such as Wes Streeting claim that they are enacting transphobic policy in accordance with ‘evidence led’ care, why is it that some experts are valued above others? When the Yale Integrity Project points out that the ‘Review repeatedly misuses data and violates its own evidentiary standards by resting many conclusions on speculation’, that ‘The Review also subverts widely accepted processes for development of clinical recommendations and repeats spurious, debunked claims about transgender identity and gender dysphoria’ and that ‘These errors conflict with well-established norms of clinical research and evidence-based healthcare’ - why is it that our government chooses to legislate without consideration of credible international criticism?

Furthermore, beyond solely the implications of research integrity, it must be understood that to argue that children inherently give an unreliable account of their own gender dysphoria, and that therefore gender diversity is an ‘adult’ characteristic, is to create fertile ground for narratives of corruption, perversion, and in some instances, paedophilia; narratives that have characterised attacks against queer people throughout history.

When the interim report and the final review were published, British media was littered with headlines such as ‘The Cass Report is a voice of reason on trans dogma that must not be ignored’ - depicting the provision of care to young trans people as if it were a national scandal, a source of shame; a runaway train of ‘woke’ ideology that desperately needed fixing. The Cass Review was correct where it outlined that access to care was not evenly spread across the country, and that trans people were suffering as a result. But where it left key areas of trans healthcare up to supposition - and therefore open to transphobic interpretation. Where it failed to mention the fact that fewer than 100 people were even receiving puberty blockers through the NHS, therefore exposing the public to vast misrepresentations of scale. This is where the real scandal lies. 

Successive governments have used the Cass Review as a key source to inform policy surrounding trans people. And yet, as has been apparent since as early as 2022: the Cass Review is a severely flawed piece of research. 

“If ‘evidence led care’ is the priority, and if policy is immovable due to its allegiance to expert consideration, well then, one would expect our government to commit to a quick turnaround.”

Labour has positioned itself as possessing a technocratic flair, choosing ministers for their expertise over political considerations. Therefore, it will be interesting to see the reaction to these recent statements made by the British Medical Association. If ‘evidence led care’ is the priority, and if policy is immovable due to its allegiance to expert consideration, well then, one would expect our government to commit to a quick turnaround. Hopefully this statement made by the BMA means that our Health Ministers will begin to see sense, and that as result, trans people in the UK begin to receive the care and dignity they deserve.