The downgrading I don't have a particular issue with. My issue is more with what's used to "fill the gaps".
E.g., there are trials that weren't downgraded, where all the people who didn't respond to follow-up were automatically deemed, en masse, to be "treatment desisters" and thus all of them were also assumed to be "detrans". But we can't infer that; it's like jumping from "we can't find anything wrong on standard tests" to "there's nothing wrong".
I'm also doubtful that the research oversight board headed by Wessely will have the rigorous standards we need to answer any questions that remain anyway. The NHS's plan for a new study into puberty blockers is also the only legitimate gateway for most young people to access those treatments now, so it creates an incentive for people to sign up to the trial and report benefits.
By contrast, there aren't any new studies looking at the long-term impact of blockers on adult trans people or people who had precocious puberty -- which could help answer a lot of questions about long-term effects and harms.
In the meantime, the use of blockers and cross-sex hormones bought online will increase without medical oversight. A lot of data will therefore fall through the cracks and young people will be reliant on costly and potentially unsafe medicines. Those who can't afford this will, as prior studies have shown, be at heightened risk of mental health problems, self-harm, risk-taking behaviours and suicide.
We already have the problem that many adults who can't otherwise afford to go private and who can't wait for NHS treatment (with waiting lists several years long) fund their own treatments overseas. Speaking frankly, many people turn to sex work to afford this, since the alternative is often unbearable for them (and holding down standard, never mind well-paying, jobs while trying to transition without any help is really hard). For children, who are also at the whims of their parents, the situation could feel a lot more bleak. (Sidenote: The biggest risk to LGBT kids is often their parents.)
In the case of ME, we have a consistent body of patient literature reporting harms for over 20 years. There hasn't been the same body of evidence for trans and gender diverse people. In fact, most trans and gender diverse people are very pleased with the treatments they receive, with a reported regret rate of 1% in most studies (lower than for knee operations, IIRC).
Of those who stop treatment via a clinic, most do so because they reach a point they're comfortable with and so they don't seek further medical intervention. They may have a prescription for cross-sex hormones but they don't need to keep engaging with a clinic for that.
It's also common for people to be more adamantly "performative" at the beginning of their journey, because that's often what's needed to convince medical gatekeepers (not to mention friends and family) of how genuine their feelings are. But once they begin receiving treatment, they're actually usually happy to stop at the point that feels right for them, and then they sort of ease into a more nuanced expression of their identity.
That's why many newly "out" trans girls wear pink and grow their hair really long, but later on are perfectly happy wearing whatever. They feel they no longer have to "prove" their gender identity to anyone. But to an outsider, this might look like regret or them "getting over it" -- in fact, its the opposite.
Most who actually "detransition", in the way the anti-trans lobby means it, report doing so because of social pressure from friends, family, etc. I.e., because they experience transphobia and return to the closet. Some who have "detransitioned" and have gone on to "retransition" again, especially when free of family and "friends" who caused them problems.
Yet the Cass Review makes quite baffling claims like saying it's easier for kids to come out as trans instead of gay, when that's definitely not the experience of most LGBT people (and many trans people are also gay, bi, etc, or ironically "become" gay or bi when they transition to their new gender).
It just reads like a review that hasn't had much actual input from people with lived experience. It also lacks the transparency of something like the NICE guidelines, and it can't be separated from the politics of those who commissioned the review.
The reality is that most trans and gender questioning young people won't seek a medical route for transition anyway, and of those who do, it's mostly puberty blockers and "watchful waiting". Cross-sex hormones and surgical interventions are usually given only in adulthood, and the latter are usually quite rare (because they're irreversible, invasive and often not wanted by most trans people).
There's certainly debate about how reversible blockers are, but the same can be said about puberty. Once people go through it, the cost for "correcting" the "side effects" becomes much higher -- if we deny people the time to wait and figure things out, they may actually be more likely to seek those surgical, even less reversible treatments later on. They may also be permanently disqualified from, say, certain sports because of the changes they've undergone, so we're effectively punishing those people twice (forcing them to go through puberty for a sex they don't identify with, and then saying they can't participate in certain areas of life because we made them do that). So we have to balance the risks there, too.
Puberty blockers are also used in precocious puberty (often at much younger ages) without huge outrage, and without any noticeable impact on reproductive health. (Which is why I think longitudinal studies of these patients could be indicative for trans/gender diverse kids.) Given that we are in the middle of a moral panic about trans people and "trans contagion", that's relevant context. When Paul Garner argues that George Monbiot is causing a spread of Long COVID just by writing about it, it's a similar argument. Ditto the argument about pwME and "online support groups".
What concerns me most about Cass is how it's already being used to advocate for a conversion therapy approach based on similar rationales to CBT for ME, and has already contributed to deepening prejudice against trans people (along with the DfE's schools guidance). This has very real impacts on people's lives.
From the perspective of pwME, however, the main concern is about Gillick competence. Gillick competence is the principle that people under 18 can make informed choices about their own healthcare if certain criteria are met. This is what allows teenagers to access sexual health services without parental consent, for example, which has been useful in reducing teen pregnancies and STDs.
For young people with ME, it also means they can advocate for themselves and decide which treatments they do or don't want.
Obviously, the principles of Gillick competence aren't applied consistently for kids with ME anyway. If adults can't choose what treatments they can/can't have without paternalistic doctors deciding for them, then it's clearly going to be even harder for kids.
But we don't want to lose those rights altogether. The Cass Review makes a meal of the "human brains aren't developed until 25" thing, and gives very little weight to the wants and needs of the children/young people by comparison. Given how quickly NHS England is acting to put the Cass recommendations into practice (again, compared to ME), we need to remain vigilant in case that sort of attitude becomes more commonplace elsewhere.
