Journal Club: Debunking the Cass Review’s Successor
Veronica Esposito debunks some of the basic claims made by the UK’s “Sullivan Review.”
by Veronica Esposito
On March 19, the UK’s government published the “Sullivan Review,” a sort of spiritual twin to the infamous Cass Review. Led by Alice Sullivan, a noted transphobe and member of anti-trans hate group Sex Matters, the review advances a number of recommendations regarding safeguarding “the availability of accurate sex-based data.” Needless to say, the Review construes the existence of transgender people as an affront to the accurate collection of such data and makes a number of recommendations that, if implemented by the UK government, would be harmful to the trans community—and potentially cis people as well.
A full debunking of the “Sullivan Review” is far beyond the scope of this article, but here I collect a number of the document’s basic claims and demonstrate how they are unconditionally false and contrary to the medical health of both trans people and cisgender people.
Claim: “People with diverse gender identities are being let down by data collection practices which conflate sex and gender identity, making it impossible to track the outcomes of distinct groups.” Essentially this is saying, “we need to misidentify trans people for their own good.”
As a related claim, the Sullivan Review flatly conflates “biological sex” with sex assigned at birth: “For clarity, the term ‘sex’ when used in this report without any qualifier simply means sex, in other words biological sex, which can also be termed natal sex or sex at birth.”
Facts: Sex assigned at birth is far from the lived sex at any given point in the lifespan, for both cisgender and transgender individuals. According to Freeman & Lopez, 2018, “there are five markers or traits on the basis of which sex can be determined: chromosomes, ratio of sex hormones, secondary sex characteristics, external genitalia (penis/clitoris and vulva), and internal genitalia.” It’s no secret that these characteristics can change for a variety of reasons, including treatment for various cancers and other conditions such as endometriosis, experiencing menopause or PCOS, regular hormonal fluctuations during the childbearing years of cis women, and being born intersex. Furthermore, many individuals frequently carry chromosomes that are atypical for their assigned gender at birth without ever knowing it—famously, at the 1996 summer Olympics, eight female athletes were surprised to learn that they had carried XY chromosomes all their lives.
It is widely regarded as best practices to not use sex assigned at birth when working with transgender patients in favor of taking organ inventories and measures of hormone status. (See, for instance, Woods et al, 2023, the UCSF Guidelines, and Irwig, 2021.) An organ inventory is simply a matter of determining which organs a patient presents with as part of developing a full picture of their potential medical needs. These are used because the organs present in transgender individuals and their current hormonal profile provide much more accurate and pertinent data than whatever sex was assigned to a patient, potentially decades ago, based on a brief look at genitals. There is also evidence that organ inventories better serve cisgender patients as well.
Freeman & Lopez further note another good reason to avoid sex assigned at birth when working with trans patients: discriminatory policies can hurt the health of trans patients by delaying care or reducing the quality of care received. They report that “twenty-eight percent of trans folks surveyed reported postponing medical care due to discrimination.” There is already evidence that exactly this is happening in the UK due to the release of these new guidelines.
Medicine is about much more than simply assessing symptoms and administering remedies. It is crucial to provide a welcoming and affirming environment for all patients, and the recommendations in the “Sullivan Review” hardly do that for trans individuals.
Claim: “The NHS should cease the practice of issuing new NHS numbers and changed ‘gender’ markers to individuals, as this means that data on sex is lost, thereby putting individuals at risk regarding clinical care, screening, and safeguarding, as well as making vital research following up individuals who have been through a gender transition across the life course impossible. In the case of children, this practice poses a particularly serious safeguarding risk, and should be suspended as a matter of urgency.” This recommendation of the “Sullivan Review” has been widely discussed, as it effectively prevents those under 18 from making social transitions. Defending the move, Health Secretary Wes Streeting has declared that “children’s safety must come first.”
Facts: There are two claims here to consider: first, that changing the sex in records somehow harms patients under 18 years of age, and that preventing social transitions does no harm to children. The former claim is addressed in the above section of this article—as previously explained, organ inventories and assessing current hormonal/body profiles are regarded as much more pertinent information with trans patients than sex assigned at birth.
As to the latter claim, we have much evidence to the contrary. Russell et al. found that using a trans child’s chosen name in more and more contexts had increasing benefits to depression and suicidality—chosen name was taken as a proxy for gender identification, and it’s easy to see how the same results could be transferred to use of the correct sex marker. Thus, even if a child is affirmed elsewhere, not affirming them at the doctor’s office detracts from their health.
Many other papers have also found benefits to children, and especially adolescents, of socially transitioning. Notably, one of the few papers to speak to the contrary, a systematic review of papers that found neither benefits nor harms to social transition only reached that conclusion by dismissing many papers showing positive results for being of “low quality,” misrepresenting the findings of others, and repeating myths about the “85% desistance rate.” Still, even that paper found no harms, contrary to the assertions of Sullivan and Streeting.
Interestingly, another paper found that bullying by peers and family dysfunction may outweigh the benefits of social transition. Perhaps experiencing invalidation and persecution by leading politicians would fit under that heading.
Claim: “Sex as a biological category is constant across time and across jurisdictions, whereas the concept of ’legal sex’ subject to a GRC may be subject to change in the future and varies across jurisdictions.” The report later states that “sex is determined at conception and is immutable.”
Facts: This is far from true—just ask Olympic boxer Imane Khelif, who has had her “biological sex” alternatively identified as “male,” “transgender,” and “female,” despite being raised as a girl and identifying as such for her whole life. Or ask Caster Semenya, who has had her biological sex distinction changed multiple times by various world athletics bodies. Or ask the White House, whose recent Executive Order identifies “biological sex” as being designated at conception, even though all fetuses begin as female and sexual differentiation does not begin until weeks into pregnancy. (We also know that it’s entirely possible for the genitals to develop in one direction and the brain in another.) Or ask the many cisgender people who have had their sex erroneously recorded on their birth certificate or in one of many Federal databases that track sex.
As this Forbes article explains, there are many different ways to identify “biological sex,” and many of them (e.g. hormonal profile; genitalia) would indicate that sex is indeed quite mutable. The one that is not mutable (chromosomes) is of little medical value, in spite of the Sullivan Review’s repeated claims that we must absolutely know a person’s chromosomal profile in order to provide them with high-quality medical care. Really? When has your doctor ever asked you about your chromosomes?
The fact is that the rage for chromosomes is a product of an anti-trans panic fomented by various groups over the past few years. Medical doctors have never systematically collected that information because it is irrelevant to their practice of medicine, and nor do most studies on the sex differences of various diseases and medicines, because whatever impact chromosomes may have are outweighed by other variables, such as hormones and organs present. (There are potential exceptions for autoimmune disorders, one of the few areas where chromosomes seem to matter.) We could very easily invent a definition of “biological sex” that included trans and intersex people, and it would likely be of greater medical use than the “assigned at birth/conception” definition—those in power just choose not to do so.
Veronica Esposito (she/her) is a writer and therapist based in the Bay Area. She writes regularly for The Guardian, Xtra Magazine, and KQED, the NPR member station for Northern California, on the arts, mental health, and LGBTQ+ issues.