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The Cass Report: High risk of bias, methodological flaws and misrepresentation of evidence.

Updated: Jun 28

More than 20 clinicians and academics in the field of transgender healthcare have critically appraised the methodology and conclusions of the Cass report using the ROBIS tool. ROBIS is a tool for assessing the risk of bias in systematic reviews. They found not only a high risk of bias across all domains but, they say, "unsubstantiated claims in the primary research that suggest a double standard in the quality of evidence produced for the Cass Report". This damning review raises serious questions as to the report's validity in directing care for trans and gender non-conforming young people.

Both Labour and the Conservatives vow to "push forward the recommendations of the Cass report", however by doing so they are potentially unleashing not only bad science but also endangering the mental health and wellbeing of young transgender people.

Supplementary tables at the end of the review reveal the problems within the report, with every single area failing: including eligibility criteria, methods used to identify studies, concerns regarding synthesis and findings and the final criteria, risk of bias.

While the British media fell over itself to publicise the results of the original Cass report, there has been media silence regarding one of the biggest failings of systematic reviews: the risk of bias. Given the demographics, and in particular the vulnerability of transgender people, young and old this reflects the sorry state of the treatment of transgender people in the United Kingdom. Several commentators from within the transgender community, and indeed from outside and in the international community have already called out the Cass report. Many raise undeniable concerns regarding the "cherry picking" of evidence and heavy reliance on "double-blind" trials as a gold standard, when in fact, such a standard was an inappropriate measure.

The UK continues to press forward with one of the most oppressive regimes against trans and non-binary communities in Europe. Trans people are already forced to declare their "sex at birth" to access healthcare in emergency departments, and other areas of health and social care. Once identified, trans women are then expected to be paraded in front of cisgender men in hospitals and changing rooms if incoming changes to the NHS constitution take place. While there is great demand in the country that cisgender women have the right to healthcare and changing areas away from men, the opposite is being forced on transsexual women who have undergone HRT and genital reconstruction forcing humiliating and degrading conditions on them. Furthermore, preventing trans children and young people from accessing timely and effective healthcare (such as Cass wants to do) not only exposes them to elevated risks of mental health problems, but also aids in the identification of them to the cisgender population.

Indeed, identification, humiliation, and degradation of transsexual women and people seem to be the political aim.

Download the full article:

Critically Appraising the Cass Review - Noone et al. (2024)
Download PDF • 300KB

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