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Opinion Trans young people have nowhere to turn, and the Cass Report has made it worse

Dr Chris Noone and Karen Sugrue respond to the recent Cass Report.

ONE THING THAT everyone can agree on is that parents generally want what’s best for their children and research suggests that parents worry most about their children experiencing mental health difficulties and bullying.

Imagine then being the parent of a young person who is trans, as many people around the country are — including an author of this article — and knowing that “one in five trans people across Europe reported being physically or sexually attacked”.

The past two years have seen young trans lives being targeted by a high-profile case involving a teacher and school, bullies storming into libraries and adults in positions of power framing them in dehumanising ways on social media.

Now, one of the few effective supports for these young people – gender affirming healthcare – has been targeted too since the Cass Review (which we contend is biased and fundamentally flawed), criticised gender identity services in the UK.

The response to it is such that Amnesty International has highlighted the danger posed to trans people by its weaponisation by anti-trans groups.

Keeping pace

Despite the great steps forward in rights and visibility for trans people in Ireland over the past 15 years, Ireland’s National Gender Service (NGS) for adults has – in our opinion – failed to keep pace with some internationally accepted standards of care and has, in the past, been rated the worst in the EU by a trans-led non-profit group advocating for the rights and wellbeing of trans people called TGEU. The NGS has a long waitlist – currently patients are being seen after 3.5 years but at least one prediction has that increasing to up to 10 years if there is no significant change. (For its part, the NGS says waiting lists will be reduced significantly in the near future as a result of planned transformations. People can see up-to-date information about wait times here.)

We don’t have a gender service for young people at all – forcing many to seek support abroad. Fine Gael, Fianna Fáil, and the Green Party promised in their programme for government to develop services for young and adult trans people according to the World Professional Association for Transgender Health (WPATH) Standards of Care, and have utterly failed to deliver thus far.

The HSE has been talking about developing a model of care for the provision of trans healthcare to young people for over a year and it is now considering how the Cass Review should inform this work. It is crucial that they consider all of the evidence in this space, not just the Cass Review, and that they also consider critiques of the Cass Review.

The problem with Cass

So, what is wrong with the Cass Review? Trans studies scholar Cal Horton has criticised it for misunderstanding aspects of the experience of being trans and we believe it does not align with best practice in terms of its methods for reviewing evidence. Its recommendations go against many international guidelines for trans healthcare (see this response from support groups in Australia).

Two key criticisms are the pathologisation of trans people and the inconsistent standards of evidence used.

The Cass Report speaks about being trans as if it is a disorder. This is counter to the ICD-11 guidelines adopted by the World Health Organization in 2019 which moved away from the practice of pathologising trans people and moved issues of gender identity from the chapter on mental and behavioural disorders into the chapter on conditions (as opposed to diseases or disorders) related to sexual health, to reflect “current knowledge that trans-related and gender diverse identities are not conditions of mental ill-health, and that classifying them as such can cause enormous stigma”.

The inconsistent standards of evidence used by the Cass Review can be seen in the systematic reviews of the evidence that Cass commissioned a team at the University of York to conduct. We believe there are several significant problems with the approach used in decisions about what evidence to include and what to ignore for their analysis – when all of the evidence should have been included.

For example, the review team excluded 48% and 36% of studies for puberty blockers and hormone therapy respectively based on what some believe is an inadequate assessment of study quality, which is against best practice and completely undermines the comprehensive nature of systematic reviews. Why they only did this in two of their reviews, and why they did this in the reviews about the two most controversial interventions – puberty blockers and hormone therapy – is not disclosed by the team.

Each of these concerns impacts the Cass Review’s approach to trans children’s healthcare, and as Horton has argued this could have negative repercussions for trans children’s healthcare rights and well-being.

Gender affirming care for young people

Why are we not taking on board the positions of the American Academy of Paediatrics, the American Medical Association, the American Psychological Association, the Canadian Paediatric Society, the Royal Australian College of GPs, and many others support? Having considered the evidence, including evidence that the Cass Review ignored, these all endorse gender affirming care for young people, which includes psychological support, preventing the worsening of gender dysphoria using puberty blockers, and hormone therapy.

The reality is that a lot of our trans kids are doing great in many ways – thriving and surrounded by love and support from their family, community and schools. But they are being let down by the HSE. We would like to be able to ensure they get the best care and support here, just as trans young people get routinely in places such as Spain, New Zealand, Canada, and Malta.

These countries have de-pathologised transness instead of requiring trans people to be given a diagnosis, they provide care in multiple primary care settings instead of a single centralised service, and they are providing gender affirming care to young people that is designed with the principles of bodily autonomy, self-determination and informed consent at its core.

There is no one way to be trans. Every trans kid is different because every kid is different – and gender affirming care can mean anything from a haircut, or a new name, or the space and safety to figure things out for themselves to the use of hormones that masculinise or feminise the body so that it fits better with one’s gender identity.

Two thirds of the country voted for bodily autonomy in 2018, and that is all that trans people are asking for. Consider another parallel with the stories we heard during the campaign to repeal the Eighth Amendment — it is not possible to stop people from transitioning, so what is happening now is that we are just denying people from accessing safe and effective healthcare.

It is well-evidenced (e.g., herehere and here) that denying access to gender affirmative healthcare for those young people who need it increases the chances of mental health difficulties, including suicidality, for them – and the biggest worry of their parents being realised. In fact, doctors from Seattle Children’s Hospital recently published an article in the journal Paediatrics that describes the withholding of care for transgender youth as “harmful to children and amounts to state-sanctioned medical neglect and emotional abuse”.

Ireland has the potential to provide excellent healthcare to trans people, young and old if it looks beyond the UK to places where gender affirmative care is implemented efficiently and effectively using an informed consent model. It’s imperative that the HSE does this so that Ireland’s young trans people and their parents get the support that is best for them here.

Dr Chris Noone is a lecturer in psychology at University of Galway and his research is focused on understanding and improving health and healthcare for LGBT+ communities. Karen Sugrue is a psychotherapist and co-chair of Mammies for Trans Rights, a group of parents and allies from all over Ireland who have trans kids in their lives that they want to find ways to support.

Dr Chris Noone & Karen Sugrue