Trans rights

[last updated 23/01/25]

Wednesday 10 April 2024 saw the long-awaited publication of the final report of the Cass Review. This report was commissioned by NHS England, and provides a review of evidence plus recommendations regarding gender identity services for children and young people.

On publication, the Cass Review’s findings and recommendations were welcomed by the majority of UK media outlets, NHS England, the Editor-in-Chief of medical journal the BMJ, conversion therapy proponents such as SEGM, Sex Matters and Transgender Trend, plus spokespeople for the Conservative and Labour parties, who promised to ensure it will be “fully implemented”.

Conversely, the Review has been extensively criticised by trans community organisations, medical practitioners, plus scholars working in fields including transgender medicine, epidemiology, neuroscience, psychology, women’s studies, feminist theory, and gender studies. They have highlighted problems with the Cass Review that include substandard and inconsistent use of evidence, non-evidenced claims, unethical recommendations, overt prejudice, pathologisation, and the intentional exclusion of service users and trans healthcare experts from the Review process.

This post provides a round-up of links to written commentary and evidence regarding problems with the Cass Review, plus quotes pulled from each. In light of these, I believe that it would be extremely harmful to implement the Review’s findings in full. 

I have had the notable displeasure of witnessing the evolution of anti-trans bills and the relentless attacks on transgender rights over the past five years. For much of that time, Republicans, buoyed by anti-trans organizations funded by billionaires and amplified by media outlets like The New York Times, have operated under the guise that their efforts were not “anti-trans.” Instead, they claimed to be “just asking questions,” “questioning the science,” or “engaging in a debate” about transgender people—as if these debates were somehow divorced from the rampant anti-trans animus that is undeniably pervasive in those circles.

They never truly were, of course, but to gain a foothold in American politics, they maintained a façade of concern for the welfare of transgender people. This is why, when reading the original Arkansas trans care ban, you won’t find overt charges that transgender people are lesser human beings who deserve to be erased in the purpose section. Instead, you’ll encounter pseudo-scientific statements like “the risks of gender transition procedures far outweigh any benefits” and “the majority come to identify with their biological sex.” Both are demonstrably false, but carefully crafted to carry a veneer of scientific credibility—providing a shield against accusations that such bans are rooted in hatred toward transgender people.

That all changed yesterday. President Trump, in justifying his transgender military ban, leaned on a new argument for why such an action restricting the rights of transgender people was necessary: that transgender people are lesser human beings, dishonorable liars, and worse.

[…]

This marks a chilling and undeniable shift. The attacks on transgender people are no longer cloaked in the faux respectability of “evidence,” “science,” or “protecting kids.” They never truly were, but now even the pretense has been abandoned. The thin veneer provided by New York Times op-eds, SEGM’s pseudo-scientific “reviews,” and the disingenuous claims of debate is no longer required. Instead, the justification is laid bare in black and white: transgender people are “dishonorable,” “liars,” “false.” The language is stark, deliberate, and unmistakable—it dehumanizes us. This is the very rhetoric historically used to justify atrocity.

So how would anyone know whether an embryo belongs to a sex that produces eggs or sperm at conception?

Anti-abortion rhetoric defines conception as happening at fertilization. [The American College of Obstetricians and Gynecologists, the leading US authority on reproductive health, defines “conception” as happening when a fertilized egg implants in the uterus.] We’re not even a multicelled embryo yet at fertilization. At that moment, does an embryo have sexed chromosomes? Yes. Are they knowable with our current technology? No. In IVF, for people who do pre-implantation genetic testing, we typically wait until at least day three, if not day five, until the sex chromosomes are even measurable. And is it a point at which the embryo is even producing gametes? No. That’s still months away.

But the executive order says these definitions should be used to determine which sex marker should go on a passport or whether a prisoner should be incarcerated in a men’s or a women’s prison.

This is what’s so stupid about it, but also what’s so dangerous. What is the enforcement plan? Are we going to test people’s gonads to see what type of gametes they produce? Because if the obsession is at the level of gametes, the tests are much more invasive than a sex chromosome test.

Nor will there be an actual way to logically enforce it, because it’s an illogical order. I think what will happen is it will be basically about punishing people in the worst way possible, treating people as poorly as possible, and creating as much discord and mayhem as possible.

This is mostly going to be around one sex category: the female sex category. They will only be doing this toward anybody who might fall into the woman category or might self-report as being in the woman category. I think Trump, in whatever terrible language is available to him, is trying to control women and control people he perceives to be in the woman category. A lot of this is keeping the category of women “pure”—and also, obviously, about doing immense harm to trans people.

There’s also a very racial, white supremacist thing going on here with this “defending women.” It’s a very old idea—it appears in travelogues, early writings of Europeans, as well as in the United States when they started encountering North American Indigenous folks, and the way that they thought about enslaved peoples. There was this belief that in the “lower races,” men and women were less different, and that in the “higher races,” there were more differences between women and men. This was about saying men and women are differentiated, clear, nonoverlapping categories because that makes us a more evolved people.

Do No Harm presents itself as a grassroots association of doctors against gender-affirming care and diversity efforts in the medical profession. The group, which was founded in 2022, does not disclose its donors. But newly disclosed tax filings provided to HuffPost by Accountable.US, a progressive watchdog, show that the Concord Fund, the funding arm of Leo’s network, donated $750,000 in 2022 to Do No Harm Action, the group’s official lobbying effort.

Do No Harm also received more than $1.4 million from a nonprofit, the Project on Fair Representation, run by conservative activist Edward Blum, new records show. Blum, a conservative activist who helped engineer two Supreme Court cases that struck down affirmative action and major sections of the Voting Rights Act, is now a Do No Harm board member.

HuffPost previously revealed that Do No Harm received $1 million in seed funding from Joseph Edelman, a billionaire hedge fund CEO, and his wife, Suzy Edelman, who has said she considers “transgenderism” “a fiction designed to destroy.”

[…]

The medley of conservative groups channeling money to Do No Harm underscores the growing belief on the right that attacking trans rights is “a political winner.”

The scale of the contributions also helps illuminate how Do No Harm became a successful influence operation so soon after its launch. Last year, the group deployed lobbyists to more than a half-dozen states to advocate for restrictions on gender-affirming care, and at least two states passed laws using its model legislative language. In Montana, Do No Harm provided the blueprint for a ban on gender-affirming care for minors, which sparked furious local protests. 

“It just made the worst of the worst people here more bold in their bigotry, and that trickles down to our kids,” Darcy Saffer, the parent of two transgender nonbinary children in Bozeman, Montana, told HuffPost last year. The law is blocked while the Montana Supreme Court weighs whether it is unconstitutional.

Wow. This is mindblowing.

For some transgender people, hormone replacement therapy (HRT) is “an ontological necessity for a livable life” (Fondén, 2020, p. 29). Some trans people engage in do-it-yourself (DIY) HRT (aka “DIYers”) because of care barriers, including medication costs, difficulty accessing healthcare providers, and mistrust in professionalized medical systems. Although DIY HRT is often framed as highly risky, we analyzed in-depth interviews with 36 U.S. DIYers to understand how they themselves perceived their goals, challenges, and risk mitigation using the Liberatory Harm Reduction and lay expertise frameworks. Participants emphasized experiences of transphobia within medical spaces. In contrast, participants characterized DIY HRT as a community-driven, accessible, and empowering practice. Through self-organized online forums and mutual aid, DIYers constructed adaptive health-promoting practices that challenge biomedical conceptualizations of risk and affirm trans agency.

A really comprehensive roundup:

In 2018, a physician and researcher named Lisa Littman published a paper in the journal PLOS One describing what she termed “rapid-onset gender dysphoria” (ROGD). She hypothesized that some young people—particularly those assigned female at birth—might claim a transgender identity after increasing their social media use or befriending trans peers. According to this perspective, online platforms supposedly “infect” teenagers with the idea that they are trans, creating clusters of youth who suddenly identify in new ways.

From the moment Littman’s paper appeared, researchers and advocacy groups criticized its methodology. Littman’s survey collected responses solely from parents recruited on three websites openly skeptical or critical of medical care for trans youth. These anti-trans or “trans-skeptical” forums—4thWaveNow, Transgender Trend, and Youth Trans Critical Professionals—advertised Littman’s survey to parents who already believed their child’s trans identity was misguided. Unsurprisingly, 76.5% of respondents felt their child was “incorrect” in identifying as transgender.

Critics also pointed out that the youth themselves were never surveyed. Parents who participated were asked to diagnose their children with gender dysphoria (a clinical term referring to distress due to a mismatch between one’s internal sense of gender and assigned sex at birth), even though most parents do not have training in psychology or medicine.

[…]

Although Littman’s original 2018 article used the term ROGD, many discussions in conservative blogs and online groups substituted or conflated it with “transgender social contagion.” This idea claims that trans identity spreads from teen to teen like a virus—an online trend rather than a real expression of self.

While the ROGD paper didn’t use the “social contagion” phrase outright, it alluded to the concept through references to “peer influence” and social media immersion. Almost immediately, these concepts were embraced by anti-trans activists, policymakers, and media personalities. The theory gave them a sort of “scientific” veneer to argue that trans kids are just “confused.” As a result, many now simply refer to both ROGD and “transgender social contagion” interchangeably, even though they are (at least in Littman’s framing) slightly different.

For activist Raquel Willis, co-founder of the Gender Liberation Movement alongside Eliel Cruz, the fight for trans rights and universal bodily autonomy has to move past the visibility era to be truly impactful.

“This idea of simply using visibility as a means to bring about the kind of culture and society that’s going to receive trans folks with the respects that we deserve is over,” she told PinkNews, “and so we have to be thinking in new ways about how to protect ourselves, our voices, our histories and our brilliance without relying on a lot of the institutions that have really pushed the visibility vehicle.”

[…]

For many, access to abortion and gender affirming care might be thought of as different social issues impacting distinctly different groups of people; things to campaign for separately but not together. This line of thinking is similar to how trans rights and women’s rights more widely are often framed by the right-wing press as in direct contrast with one another when instead they are not opposites sides of a coin but rather intricately intertwined.

New York Democrat Alexandria Ocasio-Cortez noted this in response to Mace’s bathroom ban, telling reporters in November that such restrictions endanger “all women and girls” because “people are going to want to check their private parts in suspecting who is trans and who is cis”.

“The idea that Nancy Mace wants little girls and women to drop trou in front of, who, an investigator, because she wants to suspect and point fingers at who she thinks is trans is disgusting. It is disgusting. And frankly, all it does is allow these Republicans to go around and bully any woman who isn’t wearing a skirt because they think she might not look woman enough,” AOC added.

The intersectionality between the two issues hence sits at the very core of the GLM’s mission because “many of the same forces and entities that are targeting access to abortion are also targeting access to gender affirming care”, Willis said.

Cruz explained: “In the United States, legal precedents are being used to try to pass one another. So these connections are already there in terms […] of those who are making these attacks and for us it was important to marry the different groups of people that people may not necessarily talk about in the same ways.

“Really bringing those connections together in a very intentional way.” 

I emphatically reject the author's opinion that "it’s not ridiculous to suggest, for example, that a randomized trial of puberty blockers would be a good idea." (Why not a randomised trial of ambulances? We'll send half of emergency callers an Uber instead.) But he's certainly thorough, and excepts like this are astounding.

The Cass review was an interesting juxtaposition. Some of the scientific arguments were very reasonable, and the York team generally did a decent job with the systematic reviews that informed the document. However, the review itself often positioned bizarre theories about gender dysphoria alongside data and evidence. I’ve recounted quite a few examples of this during my pieces, but I thought I’d share one more that I found recently:

“Research commentators recommend more investigation into consumption of online pornography and gender dysphoria is needed. Some researchers (Nadrowski, 2023) suggest that exploration with gender-questioning youth should include consideration of their engagement with pornographic content.” (Cass review, page 110)

This paragraph suggests that porn can potentially turn children trans. If you look up the reference, it is to this opinion piece from a psychiatrist. The paper itself contains no data connecting gender dysphoria to pornography, but basically argues that teen girls may view porn and become so disgusted with being women that they choose to instead become men. The paper also notes that “Girls affected by autism might be at higher risk because of their reduced mentalization capacities.”, although it does not provide any evidence that this is true.

The author of this opinion piece is a psychiatric trainee who lists their affiliation as Therapy First. Therapy First is an explicitly anti-medication group which campaigns to prevent children from being given hormones or puberty blockers for gender dysphoria - instead, they recommend psychotherapy as the first and in many cases only option. This is not evidence. It’s barely even an opinion. There is no reasonable excuse for the Cass review having included such a completely bizarre and unsubstantiated theory, especially without noting that it is entirely unsupported by even the most vague of evidence.

Seriously: would you test the effectiveness of chemotherapy by giving a control group of cancer sufferers saline water? I mean, assuming you're not a raving lunatic who insists that cancer is a fashionable lifestyle choice spread by social contagion on TikTok?

The absence of RCTs studying the impact of gender-affirming care on the mental health and well-being of transgender adolescents does not imply that these interventions are insufficiently supported by evidence. Although RCTs are considered high-quality evidence because of their ability to control for unmeasured confounders, the impossibility of masking which participants receive gender-affirming interventions and the differential impact of unmasking on adherence, withdrawal, response bias, and generalizability compromises the value of RCTs for adolescent gender-affirming care. RCTs are methodologically inappropriate for studying the relationship between gender-affirming interventions and mental health. These methodological considerations compound the serious ethical concerns raised by RCTs in adolescent transgender healthcare. Given the limitations of RCTs, complementary and well-designed observational studies offer more reliable scientific evidence than RCTs and should be considered of sufficient quality to guide clinical practice and policymaking. Adolescent trans healthcare is on solid footing.

a periodic reminder that these places exist:

• https://genderdysphoria.fyi/
• https://diyhrt.wiki/
• https://diyhrt.info/
• https://hrtcafe.net/
• https://transharmreduction.org/
• https://transfemscience.org/
• https://gtrr.artemislena.eu/
• https://diyhrt.market/transfem-hrt-guide
• https://www.reddit.com/r/estrogel/wiki/

and places like these:

• https://diyhrt.market/
• https://www.unitedpharmacies-uk.md

and some country specific things (please recommend more):

• https://genderkit.org.uk/

feel free to boost, and reply with other useful links for #trans people