Thread by @JolyonMaugham

So Hilary Cass' interim review into gender identity services for children and young people is just out... some initial thoughts. 🧵

First, you will read lots of views about whether Dr Cass' report neutrally captures the evidence base. One of the big problems in this space is that what is fundamentally a medical issue for specialists and patients has become a political battleground.

I'm not going to add to that problem by talking about her evidence base and I'd suggest you scrutinise the expertise of those who do. This isn't an ideological assessment. Like not needing to hold views on the proper treatment of bowel cancer you don't need to hold views on this.

On that theme, I do think this paragraph is very unfortunate. This absolutely isn't everyone's business - and describing it as such is a big part of the problem. I think, in truth, Dr Cass is talking to the medical community and not society at large...

I say that because, elsewhere on the site, she gets it right (cass.independent-review.uk/about-the-revi…): the only stakeholders are young people, their families and properly qualified professionals.

Nevertheless this paragraph is very unfortunate and I hope she clarifies what she meant.

Second point. One thing, I think, the report gets right is that there are huge shortcomings in the quality of provision at the Tavistock. That's not a moral assessment - it's not hard to find reasons why there might be failures (I've already hinted at some them) - but it is true.

And proper criticisms of the provider of the treatment (and I don't understand the Tavistock to be liked by much the trans community) quite naturally feed a narrative that the treatment is wrong. But analytically they are two different things.

Any solution to this must involve removing the Tavistock's monopoly, and its caseload that overwhelms it and thwarts good quality service, and treats gender incongruence like anything else: easy cases get treated by GPs and complex cases get pushed to specialists.

Read the interim report if you want her thoughts on this but she gives cautious support to this approach by suggesting setting up regional centres and pointing out that e.g:

There are lots of other points that might be made about the interim report but I want to make only one point more. And that is that (I think) it has ducked the core issue and so it fails gender incongruent young people.

Let me explain why I make that - vigorous - criticism. She recognises, several times, that doing nothing is not a neutral act, eg:

Let me unpack what is meant by that. If you are gender incongruent and you go through puberty your body will change in ways that do not reflect your gender identity and some of which are irreversible.

If you are a young trans woman, absent puberty blockers, your voice will drop and you will develop an adam's apple and this will make it very, very difficult for you to 'pass' as what you feel to be your gender in later life.

And, in a society that is transphobic, you know that the changes that are happening to you will impede your whole life and existence. Put bluntly, they will mean a lifetime of people discriminating against you and sneering at you.

So, by choosing not to give someone puberty blockers, someone who goes on to transition, you scar them with that life. Not prescribing is not a neutral act: it has serious detrimental effects.

And one of the main purposes of puberty blockers is to stop those changes from happening whilst the teenager reflects, before further medical interventions which are irreversible.

Dr Cass acknowledges those points. But, she says, the evidence base on the use of puberty blockers nevertheless is not strong enough. I've said I will resist the temptation to comment on that assessment and I will, so let's just take it at face value.

It's not unusual for treatments to involve risks. And the way in which the medical profession resolves these questions is by inviting patients to examine those risks. It's your life, right, not theirs, and so you get to choose.

But what Dr Cass does - and here I extract from her letter to children and young people - is say 'we need to know more.'

But, in truth, and again taking her assessment of the evidence at face value, although you might find out more (learning never stands still after all) you are always going to face the same question which is about who gets to choose.

And this is, I think, the central failure in her interim report. By talking about more evidence, she dodges the central question - which is (and however long she takes will remain) one of choice.

And the fact of her dodging that question, of kicking the can down the road (remembering she has already taken far, far longer than she promised to deliver even an interim report), will make it very difficult for the trans community to feel optimistic about where she will get to.

What will this report mean?

Well, if you are desperate to get puberty blockers, and you will be because not having them is not neutral, you will get them and the only question is how.

What this means will be different for different socio-economic groups.

Wealthy families will take their kids to private clinics abroad for a high quality wrap around service. Middle class families will construct their own patchwork of services, sub-optimally, using what they can buy affordably from private providers.

Those from poorer backgrounds - and many whose parents are not affirming - will choose to buy drugs from the dark web, sometimes with hugely damaging consequences.

And that's just the reality.

/ENDS