[AGTRT-BF101] A Dutch version of the Cass review is a good idea, but Cal Horton’s criticisms should be included

Jan Bergstra & Laurens Buijs
Amsterdam Gender Theory Research Team

It is plausible, but not certain, that a study such as the one conducted over the last four years under the leadership of Dr. Hilary Cass in the United Kingdom (see AGTRT-BF78) could also lead to relevant conclusions in the Netherlands. Jan Kuitenbrouwer and Peter Vasterman call for such an investigation in NRC of April 29. We do not repeat their arguments here, which are convincing in themselves.

But we do want to call attention here to Cal Horton’s critique in The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children (2024). Horton sharply criticizes the approach of Cass and her team. This is a good example of criticism of the Cass review from the trans community itself.

Horton’s article is long, 25 pages with two columns, and it is a remarkably detailed story, covering previously published partial studies. In our opinion, Horton’s piece is necessary literature for anyone who wants to get an idea of this matter. We repeat here the three main points of Horton’s critique.


1. Experts of experience insufficiently involved
The research team and the final responsible investigator Hilary Cass had been selected by the NHS with criteria including:

  • No professional affiliation with gender or treatment of gender-related complaints and problems.
  • No personal experience with gender transition.

Horton concludes that the Cass review did not adequately address professional expertise and a cis-normative bias was difficult to avoid.

We believe that a Dutch review of transgender youth care should explicitly include experts by experience, both professional and from the side of care seekers on the team.

2. The existence of trans children is effectively denied
Horton claims the term “trans child” does not appear in the work of the Cass review and in fact denies the existence of “trans children.” The result of that approach is that the fundamental question of transgender youth care is not even addressed, and that question is:

  • Given a youth P who self-identifies as transgender: what is the best way to support P, using methods from medicine (including psychiatry) and psychology?

Horton notes that the Cass review remains mired in a cis-prejudice-based “debate” over when the diagnosis is or can be trans valid. Horton believes that the philosophical questions about gender, gender transition and gender identity raised in the process are typically questions posed by cis people about trans people that are of no clinical relevance to trans people.

We believe that a Dutch version of the Cass review should be better prepared in terms of theoretical preparation: it cannot be the intention that such a research group has to figure out for itself whether trans children “exist” or not. This may seem like a detail, but it is absolutely not, in which Horton is very right in our view. Not assuming the “given tans child” creates a situation where non-treatment seems to be a problem-free option, but that is precisely not the case, according to professionals in that field.

3. Trans is approached too medically
A third point Horton notes is that the Cass review too easily assumes that being trans is something like a medical diagnosis. Seeing it that way is cis-normative and at odds with the gradual de-pathologization of “trans” that has been undertaken by WHO for years.

This point, too, is completely essential. Horton’s conclusion that the Cass review concerns a cis-normative study of the validity of transgder care for youth (in the United Kingdom) seems to us indisputable.


The aforementioned three points are important to include for a Dutch variant, so that the study has as little bias as possible and includes as many perspectives as possible. This is essential in a sensitive debate such as this. The trans movement is right in that in a world where cisgender is such a ubiquitous phenomenon, the trans perspective can quickly become out of sight. We in the Netherlands can also be proud of the fact that we now have a tradition of giving that perspective a central place, although there appear to be snags in this as well.

Horton points out that the specific methods of diagnosis and care in this field have long been published, and that the Cass review is apparently not interested in such work. We believe that if a Dutch counterpart of the Cass-review were to be conducted, it will be of great benefit if prior agreement is reached on the relationship between diagnosis and treatment in trans-theme, which is unusual for the medical profession. Preferably, the principles should be established first, and that conceptual inquiry should take place beforehand, and not be mixed with a quality assessment of the care provided, something that seems to have happened with the Cass review.

We also criticize Horton’s paper. Horton is quick to condemn cis-normative, forgetting that there will always be a framework of norms. We do want to characterize Horton’s text as trans-normative. And just as Horton blames Cass for keeping the cis-normative bias implcite, we can “blame” Horton for underplaying the trans-normative bias there. Whatever criticisms can be made of Cass’ research, it is also clear that there are fundamental problems in transgender caregiving that lead to strident situations in children. It is in the interest of those children that all parties involved can look at those problems without dogma in order to solve them as quickly as possible.

Whereas Horton accuses Cass of never accepting a child’s self-identification as a fixed starting point, Horton seems to believe that self-identification should always be accepted. To find a middle ground between these two extremes is impossible, and if we believe Horton, the Cass review is also on an extreme side by being insufficiently clear about when a child’s gender self-identification is taken for what it is: a starting point that co-determines further treatment.

Horton’s article contains many other criticisms of the Cass review. We think that a thorough study of the concerns raised by Horton should be part of a preliminary investigation on the basis of which an examination of the provision of care in the Netherlands can be launched.


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