The Cass Review final report has now been published. It has been received with jubilation by transphobic hate groups, by conversion therapy proponents, by those advocating against trans rights, by those who do not believe in the existence of trans children. The report has been praised and endorsed by all major UK media outlets, by MPs from the Conservatives and Labour, with both main parties committing to the fulfilment of all Cass recommendations.

The report has been met with horror and fear by trans communities, by trans healthcare professionals around the world, by families supporting trans children. Trans healthcare scholar Ruth Pearce has collated such responses here.

The Cass Review is biased and prejudice-driven in its design, delivery, analysis and approach to evidence, as documented in my peer reviewed analysis, published in the leading journal for trans healthcare.

In this short blog I will not revisit the very many methodological, conceptual, interpretive, evidencial and policy failings of the Cass Review. Instead I will here summarise and very briefly comment on ten significant recommendations of the Cass Review, each of which will cause significant harms to trans children. Here I am summarising ten of the recommendations that have me concerned, drawing from across the full 400 page report. These are not the recommendations that Cass has chosen to draw attention to in the 5 page summary document (these are analysed by Gemma Stone here) but are recommendations embedded across the longer Cass Review document. Each of the recommendations summarised below is built on a foundation of prejudice, ignorance, cisnormativity and pathologisation of trans lives, running in direct opposition to the evidence base, and running in direct contravention of an NHS duty of care to children’s rights, children’s welfare, healthcare equality and healthcare ethics.

These Cass Review recommendations have already been endorsed by powerful politicians from both the Tories and Labour. They have been endorsed by powerful healthcare stakeholders from BPS to BMJ, and there is significant high level commitment and motivation to quickly rolling these recommendations out into practice in the NHS. This roll out is a very significant safeguarding risk for trans children in England and Wales (where I refer to the NHS from here onward, it refers to the NHS in England and Wales).

1. A current complete ban on NHS access to puberty blockers.

The Cass Review recommends a complete ban on access to puberty blockers outside of a research trial, with the research trial not yet developed. There is no current route to trans children accessing puberty blockers through the NHS. All previous access routes have been closed and no new children are accessing blockers. This is not labelled as a complete ban (although it is a complete ban currently in practice) as there is reference to a potential future research trial. NHS documents have been very clear that the current ban will continue even if the proposed research trial never commences. The trial has not yet been developed, and it is unlikely that such a trial would ever receive ethical approval to commence. Even if a trial does at some future point go ahead, it is likely to be highly restrictive and unethical.

2. Legitimisation of conversion therapy

The Cass Review recommends therapeutic practices that run counter to an affirmative approach that welcomes trans lives as equal to cis lives. The Cass Review endorses ‘exploratory therapy’, a re-branded title for conversive practices. The Cass Review is careful to avoid actively calling for conversion therapy, but Cass has appeared in the media since the report’s launch speaking against a ban on conversion therapy, highlighting that such a ban could impede the type of ‘therapeutic practice’ that Cass recommends.

3. Intrusive and abusive ‘assessments’

The old GIDS service was criticised for assessments (as part of gaining approval for transfer to endocrinology) that were abusive and intrusive. Cass recommends the new service takes this intrusive approach to questioning a step further. Here this is not even a discrete step in eligibility for endocrinology (as under 16s will never be eligible for medical intervention) but an ‘assessment’ for its own sake, enforcing a prolonged intrusion into trans children’s lives. Cass recommends that trans children are questioned on a bewildering range of intrusive topics, on sexuality, on masturbation, on porn viewing, on experiences of abuse, on family violence, on mental health, on anything and everything that could have influenced them to be trans. This type of expanded questioning deeply problematises transness, and is a deeply pathologizing and abusive approach for children who just happen to be trans. It is particularly harmful for the trans children who are without support, who are left feeling there is something deeply wrong or shameful about who they are to justify such ongoing intrusions. In the old GIDS intrusive ‘assessment’ was tied to referral to endocrine services, with at least a theoretical end in sight. In the new system I see no safeguards to protect trans children from intrusive assessments that never end.

4. An immediate removal of 17 year old access to adult healthcare clinics

The Cass Review recommended an immediate cessation of 17 year olds being able to access adult gender clinics (an approach that had been adopted following the huge delays in children’s services). NHS England immediately adopted and actioned this recommendation, pulling away hope from trans adolescents. Trans youth who have already been waiting for 5+ years for access to healthcare, who some of whom were counting the weeks to the 17^th birthdays, have had this hope immediately pulled. Some 16 year olds are taking this news very hard. The NHS does not have any idea or concern for the well-being of trans adolescents who are left without healthcare.

5. Clinical control over social transition

The report recommends caution on social transition, proposing that showing respect and support for a trans child be considered an active intervention that necessitates engagement with clinical services, and by inference, clinical oversight. The process and timelines for gaining clinical permission to socially transition are unclear, but I can foresee children waiting years without clinical permission to socially transition, especially for younger trans children. Delays to social transition are harmful, shaming, and abusive, with a direct impact on trans children’s happiness and mental health. Delays to social transition are a form of conversion therapy. This approach will have particularly damaging implications for trans children in care, where care providers or foster carers may not feel able to support a child without clinical permission. It is also likely to increase delays and barriers to social transition in families who are lacking in trans-positivity, or where parents are divided in their supportiveness. My recent peer reviewed article on social transition synthesised all existing evidence on social transition, with a wide range of evidence of the benefits of social transition, and zero evidence on harm.

6. Potential restrictions for young adults

The Cass Review has already expanded into having a view on adult trans healthcare, proposing a Cass-style review of the evidence base supporting trans adult services. Given the major flaws and prejudices of the children’s Cass Review, any parallel endeavour in adult services is a very significant concern. The Cass Review talks in vague terms about changing the service for 18-25 year olds. This raises concern that this will lead to barriers to healthcare for young adults. It does not seem a coincidence that this vague recommendation aligns with the policy priorities of anti-trans actors who have long sought to restrict healthcare access for 18-25 year olds – indeed the Cass Review relies upon exactly the same flawed and misinterpreted studies on brain maturation that are used by anti-trans campaigners to advocate that trans adults are too young for mature decision making.

7. A ban on peer concordant puberty (with severe HRT restrictions even for 16 and 17 year olds)

Best practices worldwide for trans healthcare includes the option of trans adolescents taking HRT at the same time as their peers. There is growing evidence that peer concordant puberty is important for emotional well-being, physical health and educational attainment. For many trans youth, waiting until 16 to access HRT is too late, with implications for their mental and physical health.

The Cass Review recommends that even HRT at 16 and 17 be seen as an exception, with a majority denied any access to medical intervention until adulthood. The Cass recommendations to restrict HRT to 16 year olds also appear to make it harder for those who have accessed puberty blockers and HRT privately to transfer back into NHS services at 16, completely isolating trans under 18s who have gone private from returning to NHS healthcare. These approaches lead to significant inequalities between those who can access private healthcare and those who cannot, between those with or without the financial means to afford private healthcare until age 18.

8. Recommends CQC restrictions on private healthcare

The Cass Review recommends the Care Quality Commission intervene in private healthcare provision to ensure Cass recommendations are equally enforced in private healthcare. This ensures the Cass approaches, with their ban on puberty blocker access, their intrusive questioning, their ‘exploratory’ therapy, is the monopoly approach in the UK, preventing the development of any affirmative provision in private or non-GIC healthcare services. This is immediately a threat to any existing services who want to provide affirmative healthcare for trans 16 and 17 year olds outside of the Cass model. It also provides a more significant barrier to any future CQC registered private providers supporting trans under 16s. This guidance reinforces the monopoly of the Cass position.

9. Recommends Pharmaceutical Council intervention in overseas prescriptions

The Cass Review recommends the General Pharmaceutical Council takes action to prevent pharmacies from fulfilling gender affirmative prescriptions from overseas clinics. In a country where there are zero NHS or CQC registered healthcare providers prescribing for trans under 16s, action to prevent or deter pharmacies from fulfilling private prescriptions would close down the only current route to healthcare for trans under 16s. This would force desperate families into emigration or black market provision. Cass has no consideration of the NHS’s duty to adopt a harm reduction approach.

10. Problematisation of trans identities

The Cass Review has worsened pathologisation and problematisation of trans identities, legitimising those who seek discrimination under the banner of it being justified to ‘protect children’. The Cass endorsed problematisation of transness has implications for how trans children and trans communities are treated across our society.

The Cass Review reinforces a number of myths about likely parental, social, peer, abuse or porn related influences on a trans child’s identity. There is no acknowledgement that some children are trans and this is fine (or even to be celebrated). There is no recognition that being trans is a healthy part of human diversity. This message and the concerns around negative factors that can cause a trans identity in childhood can be devastating in sphere like family courts, social services, schools. It is likely to discourage parental support and provide legitimacy to abusive anti-trans families. These messages of a trans child being created through outside influence can be particularly harmful in custody battles between affirming and rejecting parents. There is no consideration of the need to protect and safeguard the well-being of trans children.