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The Cass Review on Gender Dysphoria

June 10, 2024

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The recent Independent Review of Gender Identity Services for Children and Young People commissioned by the National Health Service of England prompted much reflection on both sides of the Atlantic. Also known as the Cass Review, its author is Dr. Hilary Cass, OBE, former President of the Royal College of Paediatrics and Child Health and chair of the British Academy of Childhood Disability. In an introductory letter, she writes, “I have heard that young service users are particularly worried that I will suggest that services should be reduced or stopped. I want to assure you that this is absolutely not the case—the reverse is true. I think that more services are needed for you, closer to where you live.” This is exactly right. People suffering from gender dysphoria deserve the best care that they can get. But, as the Cass Review makes clear, it is far from obvious what in fact constitutes best care.

Writing to someone suffering from gender dysphoria, Cass notes, “Whenever doctors prescribe a treatment, they want to be as certain as possible that the benefits will outweigh any adverse effects so that when you are older you don’t end up saying ‘Why did no-one tell me that that might happen?’ This includes understanding both the risks and benefits of having treatment and not having treatment.” In the case of medical interventions for gender dysphoria, these treatments have serious side effects, such as widespread urinary incontinence. “Wetting yourself is something that just is not socially acceptable, and it stops people from exercising, it stops them from having intimate relationships, it stops them from traveling, it has work impacts,” said Elaine Miller, a pelvic health physiotherapist. She continued, “The impact a bit of leaking has on these young people’s lives is huge. It really needs to be properly discussed within gender clinics because I would expect that almost 100 per cent of female people that take cross-sex hormones will end up with these problems.” Other side-effects include the incapacity to breastfeed, infertility, and inability to orgasm. These side-effects may not matter much to a fourteen-year-old. But a life altering decision made by a fourteen-year-old may haunt the thirty-four-year-old who wishes for a satisfying sex life and a baby to nurse.

Indeed, as Abigail Shrier has pointed out in her recent book Bad Therapy, even interventions sometimes thought to be entirely benign, such as talk therapy, can have iatrogenic effects, negative effects from the intervention itself. The best intentions in the world can and do lead to adverse outcomes. For this reason, the best route to take before the widespread adoption of a medication or an intervention is double-blind clinical trials, the gold standard of evidence-based medicine. Unfortunately, no such studies have been done for those suffering gender dysphoria. 

Medical care for those suffering gender dysphoria is a wild west lacking legal regulations, empirical basis, ethical oversights, and uniform standards.

The lack of good data about the burdens and benefits of various treatments in the medium and long term is compounded by a lack of honest communication that often exists between healthcare professionals and those suffering gender dysphoria. The report notes, “We have heard that some young people learn through peers and social media what they should and should not say to therapy staff in order to access hormone treatment; for example, that they are advised not to admit to previous abuse or trauma, or uncertainty about their sexual orientation.” This lack of honest communication makes the decision-making of the healthcare professional even more difficult. 

In any case, in order to find the most beneficial ways of treating gender dysphoria, the Cass Review points to the need for open, frank, and unfettered exploration in search of optimal treatments for gender dysphoria, “As with many other contemporary polarised disagreements, the situation is exacerbated when there is no space to have open, non-judgemental discussions about these differing perspectives. A key aim of this review process will be to encourage such discussions in a safe and respectful manner so that progress can be made in finding solutions.” Such respectful, informed dialogue is needed, especially when considering recent interventions for gender dysphoria, which itself is a relatively new condition, added to the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 2013.

Indeed, the Cass Review also calls into question the appropriateness of the formal criteria for diagnosing gender dysphoria found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The Report notes, “Firstly, several of the criteria are based on gender stereotyping which may not be deemed relevant in current society, although the core criteria remain valid.” Feminist and Harry Potter author J.K. Rowling made a similar point, “Womanhood isn’t a mystical state of being, nor is it measured by how well one apes sex stereotypes.” Adopting a scientific understanding of sex, Rowling argues that to be a woman is to be female, and to be female, in all mammalian species, is to be oriented to producing gametes relatively larger than the gametes produced by males of the species. Rowling lampoons the view that, “None of that gross biological stuff matters. The only true test of a woman is whether she has magical lady feelings that make her submissive and cute and frilly and pink.” Gender stereotypes simply do not determine what it is to be male or female, so gender stereotypes do not determine what a man is or what is a woman.

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The Review also recognizes that many people, including some healthcare professionals, are deeply skeptical of treating gender dysphoria with medical interventions, especially surgery. A study from April 2024 found that, “Individuals who underwent gender-affirming surgery had a 12.12-fold higher suicide attempt risk than those who did not. . . . Gender-affirming surgery is significantly associated with elevated suicide attempt risks, underlining the necessity for comprehensive post-procedure psychiatric support.” For these reasons and others, such medical interventions are ethically problematic, especially for the young. An article in the Linacre Quarterly indicated that, if social or medical transition is not undertaken in young people, “The most recent studies report desistance rates near 85 percent.” In other words, gender dysphoria in youth resolves into acceptance of given biological sex most of the time. 

However, given that medical interventions are taking place, the Review argues that these interventions should be evaluated by the same ethical, professional, and scientific standards used for other interventions. But, so far, they are not. Medical care for those suffering gender dysphoria is a wild west lacking legal regulations, empirical basis, ethical oversights, and uniform standards. The Cass Review makes a strong case that those suffering with gender dysphoria deserve better care, and we cannot assume that medical treatment is the best way forward.