An in-depth analysis of the Cass Review and gender identity

This article first appeared in our Social Issues Bulletin – Issue 56 which is available to download here.

This article combines previous works by Dr Carys Mosely, written for Christian Concern,^[1] and Lizzie Harewood, and has been edited by Lizzie Harewood to provide an overview of the topic.

Few subjects evoke as much emotional response as the care for young people grappling with their gender identity. It’s been the subject of much debate – particularly during the recent UK General Election, with questions such as ‘What is a woman?’ taking centre stage in hustings. There’s evidence to suggest a ‘sea change’ in the zeitgeist around issues of gender and sexuality as discussed by James Mildred in his opening article of this Social Issues Bulletin. I saw James’ caution on whether the tide is actually changing, tempered by the knowledge that this is probably only the beginning of a journey away from ideologies that have become embedded within our society, healthcare, and educational institutions.

The Cass Review: A watershed moment

In April, the review led by Dr Hilary Cass, former president of the UK’s Royal College of Paediatrics, was published, creating what some are calling a ‘watershed moment’. It’s a report that will be of great interest to many Christian teachers, parents, and others concerned about healthcare and education. As the leader of the Association of Christian Teachers – an organisation helping Christians in education to live for Christ as they lead in the classroom – I’ve kept a close watch on transgender issues in schools, which, with few guidelines to support professionals supporting confused kids, seem to have spiralled completely out of control. For some years now, materials teaching concepts of gender identity in schools have been a significant concern.

The need for the Review

The Cass Review offers a sobering critique of the care provided to vulnerable individuals, highlighting multiple areas of concern and calling for a more cautious, evidence-based approach. Many Christian campaigners will feel this report validates their stance on this topic. But why was this review necessary? How did the UK – and much of Western society – reach a point where so many children feel uncomfortable with their sex?

The catalyst for a comprehensive review came from a notable surge in referrals to the UK’s Gender Identity Services for children and young people questioning their gender, and the lack of authoritative treatment frameworks to support patients seeking help. Referrals rose from under 250 in 2011-12 to over 5,000 by 2021-22, with a significant shift in demographics from prepubescent boys to mostly adolescent girls seeking help. The increase in the number of referrals has had a parallel in other countries; there was a marked increase from 2014 onwards elsewhere too.

Defenders of the authenticity of trans identities in kids argue that the increased societal conversation around gender diversity and trans acceptance allowed teens with gender dysphoria to avoid ‘suffering in silence’ or facing severe backlash for coming out; in essence, they had always existed but had simply not been able to ‘be themselves’ because of social or cultural pressure. But others suggest that alongside children suffering from incredibly real gender incongruence, some teens might have been misinterpreting their mental or emotional distress as gender dysphoria, influenced by social media and their peers, and that adults were affirming these interpretations.

Whether due to smartphones, social contagion, increasingly liberal attitudes towards gender and sexuality, or a mix of these factors, there’s been an unprecedented rise in young people with gender concerns. Acceptance of trans identities alone can’t explain the rapid increase in numbers or the shift from predominantly biological males to females presenting with gender dysphoria – a change unlike any in history. The Cass Review notes, ‘Peer influence during this stage of life is very powerful.’^[2]

Mental health and gender dysphoria

To explore the cohort in more detail, Dr Cass commissioned a systematic review of studies in the field, published in the British Medical Journal.^[3]

Who are the patients?

Nearly half of the studies reported depression and anxiety among patients, with a fifth reporting other mental health problems. Overall, children and young people referred to gender clinics had higher rates of anxiety, eating disorders, and depression than other children. Research from Finland showed younger cohorts of gender-distressed children had greater mental health needs than previous ones. The prevalence of neurodiversity and complex mental health presentations as well as childhood trauma, neglect, and abuse among patients seeking gender changes, was significant.

Social factors

Additionally, the report explored social factors contributing to the increasing desire for gender change among younger females. It points to a generation marked by anxiety, distress, and heavy digital consumption, including exposure to social media and online pornography, alongside lower self-esteem and increased body image concerns, particularly among young women and girls. Cass did not find solid evidence for biological causes for gender dysphoria in children but found that they often have multiple unmet needs and complex histories.

Evolution of ‘treatment’

The Gender Identity Development Service (GIDS), established in 1989 and operated by the Tavistock and Portman NHS Foundation Trust in London, initially took more of a ‘nuanced’ approach to distressed children and teenagers, using therapy to determine the best way to support them. Fast forward a few decades, amid the rocketing referral rates, the ‘gender-affirming’ approach seemed to become commonplace, with interventions like puberty blockers and hormone treatmnets being increasingly recommended..

However, concerns arose regarding the lack of evidence supporting the efficacy and long-term effects of these treatments, with whistleblowers raising alarm about the quality and consistency of care provided by the service.

The right way to treat

The most important question in this whole period of ‘reset’ – and especially for Christians whose mandate is to ‘Love our neighbour’ – is how can we most effectively support, and manage children and young people who present with gender incongruence and/or dysphoria?

The Cass Review’s Recommendations

Holistic approach to treatment

The Cass Review critiques the insufficient evidence supporting the medical pathway and advocates for a more holistic approach to treatment. The exclusive focus on gender for many young people meant that their other mental and behavioural problems were not considered alongside their gender distress. Of importance to schools, it raises concerns about social transitioning, urging that young children undergo therapy before pursuing such measures. Cass emphasises the importance of providing thorough, holistic, and therapeutic support, stressing the need for careful consideration of life-altering decisions in adulthood.

Puberty blockers and hormone treatments

Cass warns that the maturation of the brain could be derailed for a time or permanently by puberty blockers, stressing their potential effect on bone density and height gain, underlining the need for long-term follow-up studies to find out whether bones recover their health fully in adulthood. The review also cites a lack of evidence that interventions such as puberty blockers or hormones either ‘buy time to think’ or reduce suicide risk, and recommends that they are withheld until individuals reach 18.

Implementation of better treatment

How better treatment might be implemented remains unclear at present. Having run through various options for a new service model, in the Review, Cass describes the preferred one, which she terms ‘Clinical network plus’. In this, all patients would receive fundamentally the same treatment at all sites – consistency for all children going hand in hand with ensuring they do not just receive attention for gender distress.

To maintain care standards and access, Cass recommends that regional hubs form a National Provider Collaborative (NPC). This would set shared standards, update the patient assessment framework, develop referral criteria, discuss complex cases, and provide Continuing Professional Development.

Limitations of the Cass Review

Despite the important steps forward made by the Cass Review, we should not idealise it nor stay silent when it fails morally. Cass does not wholly oppose the practice of allowing children to live as if they were members of the opposite sex before puberty.

Concerning recommendations

Her comments on this regrettably represent a stunning lack of insight:

In reviewing cases put forward for puberty blockers, the MPRG noted that children who had socially transitioned early and completely were likely to approach puberty in a fearful and anxious state because of living ‘in stealth’.^[4]

Shockingly, Cass states that there should be no lower age limit for children’s transition options:

Helping parents and families to ensure that options remain open and flexible for the child, whilst ensuring that the child is able to function well in school and socially is an important aspect of care provision and there should be no lower age limit for accessing such help and support.^[5]

This recommendation seems odd given Cass’ advice to restrict puberty blockers to research programmes. She found that the reasons for prescribing puberty blockers had expanded over time and that these drugs do not provide the intended pause to consider gender distress, nor is there evidence that they reduce gender dysphoria. This frankly shows an attitude of not pursuing the causes of childhood gender dysphoria; specifically, not wanting to upset parents who deliberately try to change their own children. Despite our frustrations with these details, we must not overlook the positive impact and overall benefits of the report.

Political and public responses

Encouragingly, Dr Hilary Cass’ final report has received cross-party support, with both Labour and Conservative parties committed to implementing its recommendations to protect the interests of children questioning their gender identity. Politicians, such as Labour’s Wes Streeting and Education Secretary Gillian Keegan, publicly backtracked on previous statements and have endorsed the Review’s findings.

The cynic may suggest that politicians are motivated by the fear of losing voter support, influencing their responses to the Review. Campaigners’ support for politicians’ changes in stance may stem from a desire to ensure these recommendations are acted upon. Acceptance of their U-turns or apologies – even if they are opportunistic – is important in a democratic society, as it shows the need for flexibility in governance. There have been vocal critics, however, with organisations such as Mermaids and Stonewall UK expressing ‘concern’ over certain recommendations, stating they could prevent ‘children and young people from receiving the care they need.’^[6]

Christian response

The Review underscores several key conclusions that are significant for Christians. We can give thanks that much (though not all) of the Review aligns with a Biblical understanding of sex and gender. We rejoice that secular research affirms the immutable biological distinctions between the sexes while emphasising their equal worth and dignity. This ties into our conviction that God created humans in his image – distinctly male and female – and any attempt to blur these distinctions can create great confusion and distress. Biological sex matters and our understanding of this cannot be remoulded at will without significant implications.

But let’s not ‘seize victory’ at this moment in time. This is a time of lament. Thousands of young people have been harmed irretrievably. They were fed a damaging lie that they may have been ‘born in the wrong body’. They have been caught up in an ideological battle and Dr Cass herself said that children had been ‘let down’ by a failure to base care on evidence. Christians must pray for justice for those who have been misled or damaged.

We must pray that the recommendations are implemented and that there is adequate and timely support for those unsure about the next steps in treatment for themselves or their children. There are genuine concerns that these recommendations might end up left on a ‘to-do’ list without any sense of urgency. When it comes to the implications for the public sector, we must not be naïve and think it will be easy to roll back on what the media is calling the ‘ideological capture’ of the NHS or educational institutions. Christians who work in these sectors must build on this moment and use the momentum of the Review to further the calls for schools and other services to become ‘Cass compliant’ and for all lesson materials to be free from gender identity content.

And with a new government, we must ask if the political will is there. Labour’s Bridget Phillipson said she opposes using ‘partisan language’ in school guidance on teaching gender identity. The Conservative’s draft for schools which was set to become statutory guidance clearly proposed banning teaching on gender identity. However, Phillipson argued that ‘there are trans people in society,’ and thus, she would not support the ban as stated. Whatever our politics, this stance is concerning; it threatens to undo the progress made by the Cass Review and other reports highlighting the harm caused to children by the acceptance of gender ideology. We must pray that Labour keeps to its word that they will ‘work to implement the expert recommendations of the Cass Review’ and ensure coherence in the school curriculum too. However, we must not place our hope in politics alone.

Compassion and empathy

Let’s remember that, as Christ’s followers, our struggle is not against ‘flesh and blood but against the rulers, against the authorities, against the powers of this dark world and against the spiritual forces of evil in the heavenly realms’ (Eph 6:12). This truth frees us not to laud it over our ‘enemies’ or scorn those who make an about-turn on this matter. We were never really ‘battling’ them in the first place! A wise Christian will not make scornful remarks online, engage in vitriolic conversations or ‘keep any receipts’. Forgiveness and grace should define us, setting us apart from the world. Welcoming back those who reconsider their stance in light of this review and extending grace to those who genuinely believed they were acting rightly may not be easy, but as Christians, building bridges for reconciliation and change is surely our mandate.

And all the while we must remember that hurting young people are at the heart of this issue. Recognising the genuine pain of gender dysphoria does not necessitate accepting that a trans-identifying boy is truly a girl, or vice versa. But it does require empathetic listening to students or patients expressing discomfort or despair about their identity or the Review’s impact. Compassion and grace will be crucial as we navigate the aftermath in the coming weeks and months.

No longer can a Biblical view of identity or gender be nullified or demonised. But let’s use this moment wisely by speaking graciously to medics or school leaders about policies of concern; explaining with detailed reference to the Review why we cannot in good conscience use alternate pronouns; and lobbying those in authority to confirm the importance of the Review in legally binding guidance for schools.

Let us grieve that this issue has impacted so many vulnerable and impressionable young people, but may we remember that gender issues were never the cause of their biggest problem, merely a symptom of their ultimate search for meaning and identity.. May Christians be sensitive to this and hold out the hope of an identity hidden with Christ in God to a generation of young people struggling to find security.

Footnotes:

^[1]  Dr Carys Mosely wrote a series of articles for Christian Concern, the first (and subsequent articles) can be found online: https://christianconcern.com/comment/cass-review-why-are-children-uncomfortable-with-their-sex/

^[2]  Cass Review Final Report 8.56, 122. Accessed online: https://cass.independent-review.uk/wp-content/uploads/2024/04/CassReview_Final.pdf

^[3]  See: https://adc.bmj.com/content/early/2024/04/09/archdischild-2023-326681.abstract

^[4]  Cass Review Final Report 19.22, 223. Accessed online: https://cass.independent-review.uk/wp-content/uploads/2024/04/CassReview_Final.pdf

^[5]  Ibid

^[6]   See: https://www.stonewall.org.uk/cass-review