The Unintended Consequences of the Cass Review
How exposing the scandal of ‘gender affirming care’ also exposed the failure of the NHS.
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“I bet you haven’t even read it all” is a common criticism I see thrown at supporters of the comprehensive Cass Review. However, it is not one that can be applied to me. I cancelled all my engagements to read all 388 pages of it on the day it was published, absorbing its verdict on so called “gender affirming care” for minors with a zeal typically reserved for the debut of a new crime thriller. “Thank goodness for Dr Cass,” I thought as I read the final page and finally gave in to the plaintive enquiries of my partner as to whether I might now be able to do something other than manically read and expostulate about the final triumph of evidence-based medicine.
In this regard, the Review really is a triumph. However, I harbor some concerns. I’m not about to argue that the whole thing is invalid because the researchers who conducted the systematic reviews didn’t include papers in Mandarin or Algonquin, or because it is “based upon an inappropriate use of a paternalistic lens,” as some committed ideologues have tried to argue. I am greatly relieved that the Review has definitively confirmed what many with common sense knew all along: that cross sex hormones and sex change surgeries do not noticeably improve the well-being of troubled teenagers.
My concerns lie not with the overarching conclusion but with the potential implementation of Dr. Cass’ recommendations within the UK’s beleaguered National Health Service (NHS). I fear that NHS mental health services will simply trade one form of inappropriate medicalization for another. As an adult who was once a deeply distressed teenager under the “care” of the NHS, I’m afraid that doesn’t bode well for our young people.
Therapy? What Therapy?
Cass’ principal conclusion—that gender distressed youth should receive comprehensive assessments and treatments for the co-occurring mental health conditions that accompany this cohort—offers little hope for substantial change for many children currently navigating the NHS. Previously, these youths faced endless waits for appointments with the NHS Gender Identity Development Service (GIDS). Following the recommendations of the Cass Review, they are likely to find themselves on similarly prolonged waiting lists for the NHS Child and Adolescent Mental Health Services (CAMHS).
It would be nice to think that every child presenting with gender distress will receive timely assessment and tailored psychological support, as the Cass Review recommends. Yet, this outcome is supremely unlikely. As of October of last year (2023), the waiting time for a CAMHS appointment in my region spanned between eighteen months and two years—a sharp increase from the six-month wait I endured as a 16-year-old in the early 2000s, following my father’s sudden death. That period was unbearably long for my distraught and recently widowed mother. She spent those months feverishly consuming pop psychology books on teenage angst and attempting to understand the trend of “self harm” associated with emo culture—a concept utterly alien to her generation.
By the time I found myself in front of a distracted CAMHS clinician, my well-meaning Mum had me on a daunting regimen of herbal supplements and natural remedies, all supposedly guaranteed to alleviate mental anguish according to Woman’s Weekly and Cosmopolitan magazine.
Today, the situation is considerably more dire for parents of gender-distressed children. Misled by the despicable lie that their vulnerable offspring will commit suicide without access to “gender affirming” medical interventions, some parents turn to private providers for cross-sex hormones. Needless to say, the side effects of estrogen and testosterone treatment are far worse than those of St John’s Wort and evening primrose oil, in addition to being irreversible. Although the government has temporarily banned the prescription of puberty blockers in the private sector, the odious Gender GP (who employ the still more odious former Mermaids CEO Susie Green, one of the worst offenders when it comes to perpetrating the suicide myth) has announced its intention to ignore the findings of the Cass Review. This defiance recently drew rebuke from the President of the Family Division of the UK courts for prescribing a dangerously high dose of testosterone to a 16 year old girl. While Cass has clarified that the NHS is under no obligation to collaborate with private providers, I fear this stance might only drive more parents toward dubious DIY hormone treatments from unscrupulous practitioners, with gender distressed teens getting blown ever further away from the evidence-based care they desperately need.
Replacing One Form of Medicalization With Another
I welcome Cass’s conclusion that gender distressed youth should not be medicalized with puberty blockers and cross sex hormones. However, I fear that the UK’s faltering NHS might simply replace one inappropriate form of medicalization for another. Many gender confused youth transferred to CAMHS are now likely to have their distress treated with antidepressants or other psychiatric medications. This can hardly be regarded as an improvement.
I vividly remember the distress I faced as a teen when I first sought help from CAMHS. At that time, I endured a series of traumatic events beginning with my father abandoning our family to move abroad, and culminating in his untimely death. My mother was socially isolated and drinking heavily and I was her only source of emotional, social, and practical support. By 16, I was burdened with adult responsibilities for which I was ill-prepared, coping in ways you might expect for someone my age. I skipped school, drank excessively, and periodically broke down and engaged in classic “cry for help” self-harm activities, as many gender distressed young people do today.
However, the difference is that I left my first CAMHS appointment with a prescription for antidepressants rather than puberty blockers and, when these made no lasting difference, that prescription expanded to include more psychiatric drugs. Throughout this period, CAMHS never offered me counseling or psychotherapy to address the root cause of my distress. By the time I was transferred to adult mental health services two years later, I had been prescribed no fewer than five different psychiatric medications—a number that climbed to nine by age 20.
Much like GIDS, CAMHS is plagued by critical staff shortages and escalating demand. In the absence of proper psychotherapeutic and social services, there is a pervasive tendency to hastily medicalize the distress experienced by young individuals, substituting a thoughtful, multidisciplinary approach with a single prescription. While the NHS is prescribing more psychiatric medications to teenagers than ever before, the impacts of those medications on developing brains and bodies remains limited, similar to the effects of puberty blockers or cross-sex hormones. There is mounting evidence that they too can cause permanent sexual dysfunction. Despite reassurances given to patients and their parents that these drugs are non-addictive, they are, in fact, highly dependency-forming, with an increasing number of individuals reporting severe withdrawal symptoms when they try to stop. Informed consent, frequently discussed in relation to puberty blockers, is equally problematic here. I was never informed that the psychiatric medications prescribed to me at 16 were of uncertain safety during pregnancy or that discontinuing them might induce nightmarish, hallucinatory withdrawal symptoms. Ironically, despite my traumatic teenage years and long history of contact with NHS mental health services, I know now that I had never truly experienced mental illness until I faced the horrors of psychiatric drug withdrawal.
While psychiatric medications may benefit some young people, the CAMHS-to-antidepressants pipeline strikes me as scarcely better than the GIDS-to-cross-sex-hormones pipeline. Twenty years after my first CAMHS appointment I am still obliged to take two mental health medications—not because they have any noticeable impact on my mental wellbeing, but because attempting to discontinue them triggers insomnia, akathisia, pulsatile tinnitus, vertigo, and visual distortions. These are iatrogenic symptoms that were nonexistent before I began the medications. I am no more convinced of a teenager's ability to consent to these side effects than I am of their capacity to consent to osteoporosis, anorgasmia, infertility, or any of the other numerous adverse effects associated with cross-sex hormones.
Abandoning the Casualties of ‘Gender-Affirming Care’
An uncharacteristically insightful comment from transwoman Katy Montgomerie—a prominent trans activist that gender critical feminists love to hate—first drew my attention to a troubling issue affecting adult gender services in the post-Cass era. After years of obtaining hormone treatment privately, Montgomerie attempted to get her HRT prescription taken over by the NHS. However, she was rebuffed by a GP who insisted that an updated assessment by an NHS gender identity clinic was necessary—a process with a current waiting time of five years. Fully transitioned, Montgomerie no longer possesses the bits and pieces necessary to produces natural sex hormones, making the lengthy wait potentially hazardous to her health. The medical community has limited data on the long-term absence of sex hormones following sex reassignment surgery (SRS), but conditions such as hypogonadism suggest a variety of serious health risks, including an increased cancer risk.
Detransitioner Ritchie Herron has written about the awful dilemmas faced by men who detransition after full SRS. Although they may no longer desire the feminizing effects of estrogen, reintroducing testosterone can revive a male-pattern sex drive, which becomes problematic without the corresponding physical equipment to do anything about.
Fortunately, Montgomerie can afford private treatment, but other adult transsexuals in the UK are not so lucky. Since the release of the Cass Review, transgender Reddit forums have been flooded with nightmare stories about NHS providers abruptly terminating shared care agreements with private providers or refusing to issue hormone prescriptions. This leaves many fully transitioned adults at risk of serious health issues if they cannot afford private care. Although Cass’ verdict on shared care agreements reaffirms existing NHS policies, it ostensibly offers overburdened GPs a reason to decrease their heavy caseloads. According to the British Medical Association, the average GP now oversees a staggering 2,294 patients and is typically obliged to take 12 more appointments per day than is considered safe. The opportunity to offload a few patients on the basis of shared care technicalities will be hard to resist.
The ramifications of these attempts to curtail clinical responsibility amidst overwhelming pressure on the NHS are profoundly distressing for patients. They often find themselves compelled to make what amounts to a professional sales pitch for treatments they are legally entitled to or clinically require. I recall once being denied psychotherapy for what was then diagnosed as borderline personality disorder (BPD) because my articulated “treatment goal” of “To get better please” was judged as insufficiently clear. Like most people without a psychology degree, I wasn’t entirely sure what the recommended treatment for BPD actually was, making it hard to set specific “goals” about it before consulting a psychotherapist. I remember wondering whether patients were ever declined heart surgery because they could not specify the need for a triple bypass in advance.
This closely mirrors the situation that Montgomerie faced—a trans-identified male trying to persuade an NHS clinician that it is too late to decline HRT when someone has already been surgically castrated. Regardless of our views on the future of gender medicine, I hope we can all agree that people who have already made life altering changes to their bodies must have access to the treatments necessary to their health.
Conclusion
Even 15 years ago, when I was being declined psychotherapy, overworked NHS mental health professionals were squeamish about complex cases, favoring patients who seemed to have predefined their treatment needs. I suspect they might have felt some relief when a wave of gender-distressed adolescents emerged, each articulating clear “treatment goals”—though these were often influenced more by social media influencers than by medical professionals. This situation required merely a singular referral to endocrinology, after which these patients could swiftly be classified as “not my problem anymore.”
Pre-Cass, CAMHS certainly leapt at the opportunity to offload responsibility for patients presenting with gender distress. They frequently declined to address co-occurring mental health issues until after the patients had consulted with specialized gender services. Consequently, young people were left without any mental health support while languishing on the interminable GIDS waiting list.
Whether or not it relates to gender, getting to the bottom of profound human distress is a messy and time-consuming business, not easily addressed in a single consultation with an NHS clinician wilting under burn out, or with a hastily prescribed medication that might ultimately create more problems than it solves.
“Thank goodness for Dr Cass.” I stand by my initial reaction. Yet, while the Cass Review has exposed the scandal of so called “gender affirming care,” it has also inadvertently exposed the broader crisis of the UK’s failing health service. As things currently stand, the NHS is ill-prepared to implement Cass’ recommendations concerning psychological care, as it simultaneously perpetuates the cycle of inappropriate medicalization and searches for loopholes to diminish its responsibilities toward gender-distressed patients.
While Americans wrestle with the unique challenges posed by a for-profit health system, we in the UK must grapple with the dire state of the NHS and the sad reality that so-called “gender affirming care” is unlikely to be the last medical scandal it gives rise to.
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I don’t understand why the common condition of puberty anxiety is never discussed.
These children enter puberty, are distressed about adulthood, misattribute fear of (male,female) adulthood with being male or female and then the rollercoaster starts.
All adolescents have puberty anxiety, since all humans have anxiety as their body changes. It’s an instinct of self preservation.
Sudden clumps of hair and lumps growing on the body, acne and weight-gain are problems in any other context.
It’s startlingly difficult to find discussions on the most obvious source of distress.
Would that a different source were identified I wonder how dire your thesis would remain… because it’s definitely gruesome.
Thank you for this very interesting article. I fear you are correct in many of the things you say. Doctors in the UK have been far too ready to reach for the prescription pad - rather than, say, referral to counselling services - for a very long time. They jealously guard their prescribing privileges by over-using them to the point that I find it difficult to regard most of their work as that of skilled technicians. (I know there are some excuses for this in the UK today , such as the overwork you mention, but it is just a worsening of the situation that has been going on for decades.) The big question, though, is what alternative(s) can be put in place quickly and efficiently? Where, for example, are thousands of counsellors going to come from, and how do we make sure that they aren't trainned by the lunatic ideas of trans ideology? How do we reduce GPs workloads so that the "Dr Finlay's Casebook" dream (which never existed for most people, I know) can be approached, if never met? I have no good answers, but I hope someone else does, otherwise we are all up the creek without a paddle, and many more children and young people are going to be iatrogenically.
Hmmm, too late at night for these depressing thoughts. Good night all.