Cass Says Transition Should Be Measured By “Employment," Not Satisfaction

Dr. Hillary Cass, author of the Cass Review gave an interview with NPR in which she says that transition effectiveness should be measured by "employment" and "getting out of the house."

Ted Eytan/Creative Commons

On Wednesday, Dr. Hillary Cass gave her first American interview with NPR about the Cass Review. The review, which appears heavily politicized and lends credence to debunked theories about being transgender, such as "social contagion," is being used as a pretext to ban care in the United Kingdom. In the interview, Cass called for "other ways" of managing dysphoria besides transitioning and blamed being trans on factors such as autism and pornography. However, one particular point of note was her response to a question about the evidence supporting gender-affirming care, where she suggested that the real measure of transition success should be the employment status of transgender people.

When asked about “actual outcomes” for the effectiveness of cross-sex hormones in transgender youth, Cass sated that there was a need for long followups to see if transgender people thrive on hormones, and that the outcomes that she was most interested in included employment, “getting out of the house,” and relationships. See her answer here:

CHAKRABARTI: Regarding cross sex hormones, the systematic review authors said there is a lack of high-quality research assessing the actual outcomes of cross sex hormones.

CASS: Yes, because we need to follow up for much longer than a year or two to know if you continue to thrive on those hormones in the longer term. And we also need to know, are those young people in relationships? Are they getting out of the house? Are they in employment? Do they have a satisfactory sex life?

It is important to note that all of these potential outcome measurements may be heavily influenced by transphobic sentiments in society. Should transgender people be judged on their ability to be "employed" or their willingness to "get out of the house," their own discrimination may then be used against their ability to access medication. According to the National Center for Transgender Equality, more than one in four transgender people have lost a job due to bias, and three-quarters report experiencing workplace discrimination. Therefore, it is inaccurate to blame transgender people and their medication for what appears to be an issue with societal discrimination.

In recent years, many reports have emerged showing high levels of satisfaction and low levels of detransition for transgender people. A recent report in the 2022 US transgender survey shows that out of 90,000 transgender people, less than 1% report feeling less satisfied after beginning gender affirming hormone therapy, with the vast majority feeling “a lot more satisfied.” Detransition appears to be similarly rare. One recent study out of Australia found complete data on 548 of 552 transgender patients and discovered only 1% of transgender youth detransitioned over several years before being transferred to adult services. Another study showed that transgender youth are stable in their gender identity 5 years after transitioning, with only 2.5% reidentifying as their assigned sex at birth. Even Cass’s own report found less than 10 detransitioners out of the 3,000 trans youth patients in England, which led to her claiming that the real reason she didn’t find more detransitioners is because adult clinics refused to provide private patient data.

Nevertheless, there has been a recent push from those opposed to transgender care to discount the high satisfaction reported by transgender people in favor of outcome measurements that are conveniently impacted by anti-trans sentiments, which they may help foster. Anti-trans writers Jesse Singal and Ben Ryan have both promoted the idea that transgender people may be lying about their own happiness and the positive impact of transition on their lives. Jesse Singal, when faced with rising evidence that detransition rates are actually low, stated, "There's no good data suggesting anything one way or another. We have no idea how many American youth are happy with their decision to medically transition," and that "what we need is more objective outcome data." Similar claims appeared in the highly editorialized and error-ridden "WPATH Files," which stated that transgender people are "suspiciously happy," seemingly arguing that there is no way transgender people could be so happy given the discrimination they face on a daily basis.

The idea that transgender people are “unreasonably” or “suspiciously” happy in the face of poor “actual life circumstances” has a long history in the mistreatment of transgender people. In 1979, Conservative Activist doctor Paul McHugh abruptly ended gender affirming surgeries at Johns Hopkins. He based the decision on a study that judged the effectiveness of transition with employment status, legal difficulties, and entering into relationships (notably, points were deducted for transgender people entering into gay relationships). Surgeries have since restarted, with Hugh’s history being described as “a long shadow” cast on Johns Hopkins Hospital.

In the interview with NPR, Cass appears to have been comfortable in openly reviving those old criteria used to deny gender affirming care for transgender people. These criteria allow those opposed to transgender people receiving their medical care to use their own discrimination against them. In advocating for such measurements, Cass can advocate against transgender people receiving gender affirming care while pushing the idea that her report and those who follow it are behaving in an “objective way.” We know from history and current attacks on transgender people that there is nothing “objective” about such proposals.