The Cass Review Buried Trans Youth Perspectives
We got into the weeds on the Cass Review website to surface the youth perspectives Cass ignored in a report that seems certain to further limit options for gender dysphoric youth in England.
by Evan Urquhart
England’s Cass Review was commissioned to examine the provision of gender-affirming healthcare in England and provide suggestions on improving the service. However, when the final Report was released, discussions of what had gone on in the GIDS service were de-emphasized, with results such as the extremely small number of detransitions identified (Cass found fewer than 10 in over 3000 patients) being buried in the appendices while other things, like unsupported speculations about the causes of gender dysphoria, were placed in the main Report body.
Why the Report de-emphasized its own investigation into the GIDS service in this way is unknown, although some members of the transgender community have speculated it was due to bias or a desire on the part of the writers to ensure the Report fit into some pre-determined conclusions.
Among the de-emphasized material were a series of focus groups with trans youth and young adults who had previously accessed the GIDS service, conducted at the behest of the Cass Review. The information from these focus group sessions is available on the Cass Review website in the form of about ten pdf downloads.
It’s an unwieldy and poorly summarized data set, but one worth engaging with for those who are interested in what trans youth tried to tell the Cass team, and whether the team genuinely engaged with their feedback.
Focus Groups Shared Frustrations With GIDS
The first takeaway from the focus group material is that trans youth and young adults were extremely dissatisfied with the GIDS service. The most frequent complaint was long wait times, which were mentioned occasionally in the Cass Report document. However, another frequent complaint was that trans youth felt the assessment process was too onerous, that they felt on trial to prove their were trans enough to deserve treatment, that it set up unnecessary hoops to jump through, and that young people felt they couldn’t be honest with their providers because any “wrong” answer risked being denied access to the healthcare they needed.
“They probed me so hard for any "alternative" reasons I may have been trans initially (such as other childhood trauma, with emphasis on sexual assault) and it just felt like they were finding any reason to "disprove" me being trans in my first appointment.” –LGBT Foundation focus group participant
“I honestly just felt like they were trying to trip me up. It felt quite…I don't know..inhumane… it just felt like I was being tested about what I was saying about my own gender. Almost like, yeah, like an interrogation…I don't know if that's their purpose, but that's what it felt like to be on the receiving end.” –Gendered Intelligence focus group participant
This description stands in direct contrast to media narratives in the UK, that have repeatedly suggested the GIDS service provided medical transition too easily and quickly. This apparently false view of the service has become the dominant narrative in mainstream UK media, including respected sources such as the BBC.
Despite amassing ample evidence to contradict this widespread misperception in both the focus group sessions and findings on the number of appointments youth received (Cass found patients had an average of 7 appointments before a referral to endocrinology, and that fewer than a third of patients ever received such a referral), the Cass Report seems to have made little or no effort to correct the record.
In fact, with its recommendation that hormone therapy be provided to youth under 18 only with extreme caution, the Cass Report implicitly suggested this was not what was already happening at GIDS. The focus group accounts suggest the opposite may have been true: Numerous repetitive appointments, arbitrary wait periods, and skeptical providers meant that providers already seemed to show extreme caution (or at least extreme reluctance) before providing access to medical transition. This raises the question of whether these specific recommendations by Cass constitute a change from what was already being done and, if not, why they were needed in the first place.
At the very least, the Review seems to have decided to retain the aspects of the service focus group participants said they most hated, without being transparent about this or providing any evidence that maintaining this approach was benefiting the patients.
Detrans Participant Asked Cass Not to See Transness as a Bad Outcome
Another theme in the focus groups was that the youth felt multiple ways of being trans or gender nonconforming were equally valid, and that providers shouldn’t push patients towards a one-size-fits-all medical transition or a cisgender identity. One repeated theme was that there should be room for nonbinary people to explore medical options to treat their dysphoria and for binary trans people to explore non-medical options.
Of particular note is one focus group participant who identified as detrans, whose full responses* were provided in a spreadsheet of supplemental material for the Proud Trust focus group. Far from expressing regret or a need for more caution, this detrans 20 year old spoke of frustrations with not being believed or offered testosterone fast enough and called the assessment process useless because it did not lead to a testosterone prescription.
Writing about what they would prefer from the service, the detrans respondent wrote, “I would prefer if they treated it as a chance to support you, rather than an opportunity to scrutinize you. They aim to prevent detransition when they should be aiming to aid transition. Feeling as though I was under scrutiny and had to prove myself forced me to double down on my transmasc label far past when it stopped fitting me.”
Fear of Transphobia
Among the most poignant themes in the focus group responses was the awareness of transphobia in the UK media, among parents, schools, GPs, and the public, and in the GIDS service itself. Participants asked about names for a new gender service suggested leaving “gender” out of the name or otherwise making sure there was a way for their privacy to be protected when they accessed it, out of fear of transphobia. They explained that transphobia in the media was the reason they sought information from non-traditional sources, and their hopes for improvements in the service were grounded in an understanding that the process they were engaged in was being marred by transphobia.
On a name for a new service, a participant in the 42nd Street focus group wrote, “Don't use explicit names that can relate to gender services, like 'silly funny gender place', something subtle and unidentifiable, yet has some kind of symbolic meaning.”
This fear about privacy being compromised would seem to contradict the widespread impression that trans youth advertise their transness for popularity or attention.
“Transphobia isn't just existent in strangers, it's also there within families and friends. Transphobia will always be a barrier, but we need to take steps to make sure people can access services in a way that trans people can be protected.” –42nd Street focus group participant
*NOTE: The material in this section is no longer publicly available. It is unknown why it was accessible at the time Assigned published our story, or why it was subsequently removed, but the other focus groups’ material does not include the specificity of data that once appeared in that, previously public, spreadsheet.
Evan Urquhart is the founder of Assigned Media and an incoming member of the 2024-2025 Knight Science Journalism fellowship class at MIT.