Gender Transition

[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. 

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.

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

Assuming a lot more people will need this info soon.

⚠️ DISCLAIMER: THIS WEBSITE IS FOR INFORMATIONAL PURPOSES ONLY AND DOES NOT PROVIDE PROFESSIONAL MEDICAL ADVICE.

Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen.

This website intends to teach transgender people how to safely perform DIY Hormone Replacement Therapy. Share the site with those who need it, but not to transphobes: use common sense!

Whether it's due to cost, familial issues, or a myriad of other reasons, for many trans people HRT is inaccessible. If you or someone you know fit into this category, this site is designed to help.

A touching (and personally resonant) little story from Tattie, a dearly valued member of my Fediverse parasocial circle:

Even before marriage, I had always had an aversion to buying “stuff”. I always tried to get by with the bare minimum, the cheapest things, the most practical. I never felt I deserved good things, and often I didn't have a good sense of what it was I wanted, exactly.

Speaking to other transfems, it seems it's quite a common experience. Before we start to grow into our true selves, we tend to live small lives, unassuming ones. Self-sacrificing lives. If we can do without, we do without.

I remember in university feeling too guilty to buy name-brand chocolate biscuits, going for the store-brand ones instead. A matter of perhaps twenty pence, but twenty pence which I thought didn’t deserve to be spent on me. I remember living in the cheapest clothes I could find, and wearing them until they were full of holes. Cycling everywhere because getting a bus would be too bougie, apparently.

It wasn’t about needing to save money. It was about self-denial. Self-denial had become a virtue in my mind— I justified it with half-understood stoic philosophy and Buddhism, but even without that philosophical framework I would be doing it.

Why?

Because I had been told I had to live in self-denial. To pretend to all the world that I was a boy, to tamp my feminine nature right down so that nobody would notice, nobody would suspect. And if this was good and right, well, self-denial must in general be good. Otherwise what was I doing this all for?

We looked at the latest research from around the world to understand what knowledge was being used to inform the care of children and young people with gender dysphoria by looking for research published in the scientific literature between 2019 and 2023. This work builds on a previous report we provided to NSW Health summarising the research published between 2000 and 2019.

We found 82 research studies published since 2019. This represents a rapid growth in research in this field. Various methods of varying quality were used to gather information in these studies. While we found that there hasn’t been a significant increase in the use of gold-standard methods (such as, randomised controlled trials (RCTs)) in this emerging field of research, we were still able to draw out meaningful insights into the effectiveness and risks of gender dysphoria treatments. The research we found provides a good starting point for discussing critical issues with patients, caregivers, and healthcare providers, including deciding where to invest in future research.

NSW Health will use this review’s findings to guide various projects designed to gather more information from experts and people with lived experiences, with the aim of providing safe and effective psychological and medical treatment services for young people with gender dysphoria.

This isn't earth-shatteringly important. Just kind of sweet.

I had become resigned to living the rest of my life as if it belonged to someone I emailed with a few times but never actually met, but then came an unexpected 12-month span that turned everything around. My son had graduated from college and my daughter had just started, so they had clearly moved on with their lives. I discovered home movies of my biological dad, who had died before I was born so I’d never seen anything but some photos of him. I turned 60. And there was a pandemic, which brought with it endless hours of isolation and contemplation.

[…]

Once you’re past 60, your internal “fuck counter” hits zero, so I have none left to give. I don’t have time to waste worrying about what others think of me. I only have time to let others see that it’s never too late to be who you’ve always wanted to be.

It’s taken so long for me to find my path, but now that I have, walking along it appears to suit me. Recently, I had drinks with some friends I hadn’t seen for a while. After a couple of minutes, one of them stared at me, waving her hands in my direction, and said, “This just feels right.” That was a phrase I honestly never thought I’d hear.

This:

It’s important to understand that hormones, surgeries, and other aspects of transition do not always result in the dramatic physical changes many of us hope for. HRT, in particular, is often seen as a miracle cure that will bring about rapid changes in fat distribution, breast development, and softening of facial features. While HRT can bring about incredible and affirming changes, it’s not a magic wand. The results can vary widely depending on factors such as age, genetics, and individual body characteristics.

At 55, my body doesn’t respond to HRT in the same way that a younger person’s might. The progress has been slow, and while I am grateful for every sign of change, the truth is that I may never fully meet the physical expectations that the world imposes on women. And that’s devastating—not because I want to conform to societal ideals of beauty, but because I want to feel comfortable in my own skin and be accepted for who I am.

The relentless pursuit of passing can also lead to harmful behaviors. Some transgender women may resort to extreme dieting, over-exercising, or engaging in risky procedures to try to achieve a more “feminine” appearance. The focus on passing can overshadow the actual goal of transitioning: to live authentically and find inner peace. Anxiety, depression, and a sense of failure can take the place of the joy of transition when the emphasis shifts from self-acceptance to meeting external standards.