The Cass review has methodological flaws and is informed by cis-normative ideology, writes Oscar Chatfield Negowetti / Wikimedia Commons /

Last month, Dr Hilary Cass submitted the final report of the independent review of gender identity services for children and young people. This report has been welcomed by large swathes of English civil society and by both the Conservative and Labour parties, who have announced that they will implement its recommendations in full. However, the review’s findings have not been unproblematic, and it has been widely condemned by healthcare professionals, academics and human rights professionals, who have all pointed out that its recommendations are at odds with expert consensus and the majority of clinical guidelines around the world. Additionally, it has proven controversial within Cambridge. The Cambridge University Labour Club (CULC) released a statement voicing their opposition to the widespread acceptance of the Cass review’s findings, and academics have signed letters to dissuade adoption of its recommendations.

The opposing perspectives on the review present it in a highly contrasting light. Proponents of the review have welcomed an ‘evidence-led’ approach to trans healthcare and applaud its ability to side-step ideology in the treatment of children. Critics have been quick to point out some of the methodological problems with the Cass Review. The use of randomised clinical trials as one of the metrics for assessing the quality of evidence has been particularly prevalent in debate on the applicability of the review’s findings. However, the problems of the Cass review are much more nuanced than a single methodological weakness that renders the report entirely untrustworthy. Instead, they reveal deeper problems with the ways that gender is understood, rationalised and medicalised in prevalent discourse, and demonstrate the fundamental inability of a scientific approach to comprehensively explain issues of gender.

“Cis-normativity underlies the logic of the review”

A key recommendation of the review argues that “long-term gender incongruence” should be an essential prerequisite for medical treatment as there is insufficient evidence to suggest that children questioning their gender will go on to have a fixed trans identity in adulthood. Aside from the low number of people who decide to detransition after receiving hormonal treatment, this recommendation also reveals the fundamental cis-normativity which underlies the logic of the review. To the authors of the Cass review, it is preferable for trans people who would benefit from treatment to be denied it as long as others who might change their minds at a later date do not start the process of medical transitioning. This undermines the legitimacy of trans gender identity and assumes the greater validity of cis gender identities.

Moreover, none of the authors had previous experience of researching or providing healthcare in gender identity services. Trans people and experts in gender services were assumed to be unreasonably prejudiced. A psychiatrist at a gender identity clinic in England told the Sunday National: “I can think of no comparable medical review of a process where those with experience or expertise of that process were summarily dismissed.” This suspicion further reveals the Cass review’s bias that conclusions which supported access to treatment for children had to be ideologically loaded, whilst the review itself was (falsely) presumed to be impartial.

“The NHS’s gender services do need urgent improvement, but this improvement should not be led by a review informed by a presumption of the superiority of cisness”

These assumptions render the review unable to properly deliver a fair assessment on access to gender affirming care among children and young adults. Its preconceived cis-normativity naturalises cis identities and views them as preferable to deviations from, or within, the gender binary. This bias informs the argument against social transitioning and the use of puberty blockers on the grounds that these interventions will change the outcome of somebody’s gender identity and cement them into an existence as trans. An experience of puberty, the review supposes, is all that is needed to convince people that they are cis.


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The argument that the Cass review takes a neutral, evidence-first approach to generate serious recommendations for trans healthcare services are thus demonstrably false. It is at least as informed by ideology as its opponents and perpetuates its presupposed view of the lesser legitimacy of trans gender identities in its conclusions. It makes these recommendations with little care for the deeply harmful and traumatic consequences that a denial of healthcare has on trans children, and relies on the epistemic privilege of science to circumvent the complexities of everybody's experiences of gender.

While the Cass review does not adhere to methodological best practice, it is the legitimacy lent to it by science that makes it particularly counterproductive to public conversation and policy. As long as objective science continues to be treated as the superior means for understanding our reality, the subjective, cultural and non-binary experiences of gender will be overlooked. To be clear, the NHS’s gender services do need urgent improvement, but this improvement should not be led by a review informed by a presumption of the superiority of cisness. As a result of the implementation of its recommendations, the Cass review will lead to the unnecessary suffering of a greater number of trans children.