The Cass Review’s final report: The implications at the intersection of trans and neurodivergence
Neurodivergent academic Abs S. Ashley critiques the ‘insidious mobilisation’ of neurodivergence to undermine the agency of transgender people in the UK’s recently published Independent review of gender identity services for children and young people’.
On 10th April the final report of the UK’s ‘Independent review of gender identity services for children and young people’, led by Dr Hilary Cass, was publicly released. The report claims to outline evidence-based healthcare approaches for children and youth seeking NHS support for gender-affirming care, insisting that it is not about ‘defining what it means to be trans […] undermining the validity of trans identities, challenging the right of people to express themselves, or rolling back on people’s rights to healthcare’ (2024:12). However, it was immediately condemned by trans persons and allies for its erasure of transgender histories, its highly selective usage of existing literatures, and its vague and unsubstantiated statements. The report, and its recommendations to extend child-oriented services to the age of 25, were deemed by many as overtly transphobic, and echoing the incoherence of conservative ‘anti-gender’ trends that currently saturate cultures across the Global North.
Amongst many notable problematic instances of transphobia, the report selectively mobilises neurocognitive, neurodevelopmental, and psychosocial disabilities including autism, emotionally unstable personality disorder (EUPD) and Tourette’s, to undermine the credibility of transgender people’s testimony about gender-related distress. It frames neurodivergent trans persons as ‘potentially vulnerable into their early 20s or longer’ (94). Rhetorically, this emulates the disjointedness of pre-existing attacks on neurodivergent and trans persons, including that former children’s author and the right-wing press.
The report argues that gender-related distress and subsequent mental health problems ‘may be associated with and influenced by other factors, including experiences of neurodiversity [sic] and trauma’ (120). The fact that autistic people and other neurominorities are more likely to be transgender is well documented in autoethnography and scholarship; in generative ways that position neurodivergence as a vital intersection of experience. Lydia X.Z. Brown, for example, uses the term ‘gendervague’ to signify how ‘being autistic doesn’t cause my gender identity, but it is inextricably related to how I understand and experience gender’ (2016).
The Cass Review ignores the expansiveness and richness of such literatures. Though it repeatedly refers to ‘neurodiversity’ and ideas of ‘difference’ rather than ‘impairment’, this functions as a linguistic red-herring. It reflects how the inclusive roots of neurodiversity paradigm thought and language have been misappropriated by those with superficial, self-interested, or even exclusionary interests. The report states:
Difficulties with intereoception (making sense of what is going on in their bodies) and alexithymia (recognising and expressing their emotions) can sometimes make it hard for these young people to express how they are feeling about their internal sensations, their gender identity, and their sexual identity’ (93)
Although this appears to indicate concern it is, what Mikey Elster has described as ‘insidious concern’; a phenomenon that ‘couches critique in terms of benevolence’ (2022:409). Autistic subjectivities of gender and sexual identity are collapsed in terms of impairment, and recall the harmful rhetorics of Theory of Mind discourse. Theory of Mind frames autistic people as deficient in their understanding other people’s desires, mental states, and beliefs, but also in terms of self-awareness. As autistic researcher Remi Yergeau, writes, ‘god theories’ such as these, ‘transpose facets of autistic personhood into sterile symptom clusters’ (2017:11). Such facets, they explain, are viewed in terms of totalising defect: ‘intent, feeling, sexuality, gender identity, and sensation […] all of that which might be used to call oneself properly a person’ (4). In discrediting trans people by pathologising non-normative emotional responses to gender-related distress, the Cass review is both ableist and transphobic in its gatekeeping of how gender identity ‘should’ be expressed.
Cissexist rhetorics also make up this part of the report. They disproportionately target transmasculine and non-binary persons assigned female at birth, but rely on opacity to do so. Firstly, the phrase ‘undiagnosed autism which is often missed in adolescent girls’ sits beside ‘[o]thers may go on to receive a diagnosis of emotionally unstable personality disorder’ (93), but without elaboration. Doing so rhetorically invokes the misogynistic histories of EUPD diagnosis (also known as borderline personality disorder) and its disproportional attribution to cisgender women and queer people. Individuals with this diagnosis are, as Merri Lisa Johnson puts it, ‘universally villainized in the Western cultural disability imaginary’ (2021:636), even in the context of healthcare where individuals are habitually discredited by service providers. The report also ambiguously refers to ‘functional tic-like behaviours’ that are viewed as precursory to a Tourette’s diagnosis in AMABs, but as ‘tic-lookalike patterns, usually triggered by exposure to videos portraying tic-like behaviours on social media’ for AFABs. Anti-gender imagined fears of trans contagion are re-mobilised through the report’s invocation of highly misogynistic cultural stereotypes of neurodivergence, whilst capitalising on a general fear of social media as a vehicle to contagion.
What is even more concerning is how the report engages with other potentially co-existing forms of disablement including anxiety, depression, eating disorders and OCD. Although Cass concedes that such ‘individuals identify and communicate experiences of stress/distress differently from other neurotypical individuals’, the report then uses this collective analysis of neurodivergence as justification to place all individuals with these experiences as ‘potentially vulnerable into their early 20s or longer because of their tendency to want black and white answers, and their difficulty in tolerating uncertainty’ (94).
The Cass Review, in much the same way as ongoing transphobic trends in current political and cultural discourse, insidiously mobilises neurodivergence with dehumanising and agential consequences for disabled and trans people. It positions neurocognitive, neurodevelopmental, and psychosocial disabilities as pathological causes of gender-distress, rather than as legitimate intersections of human experience. As a result, trans youth, and adults up to the age of 25 seeking affirming healthcare are stuck in a double-bind. They are obliged to story their experiences of gender-related distress in neuronormative ways, at the risk of being discredited. Yet, this ideal cannot be grasped if gender-related psychological distresses are, in turn, pathologised as ‘symptoms’.
The implications of this framing are significant. Whilst the report cites adjacent NHS services using 0-25 models to justify a ‘continuity of care’ (224), designating trans persons as ‘vulnerable’ and confining them to child-oriented services indicates that more is at stake. These rhetorics contribute to the shoring up of state surveillance and intervention into the lives of legal adults who want to make choices the state disagrees with. In a landscape where neurodivergent and m/Mad people, disabled people, queer people, global majority persons, and those seeking contraception and abortion care are also being systematically targeted by ultra-conservative exponents, it sets a worrying precedent moving forward.
References
Bassi, Serena and LeFleur, Greta. 2022. ‘Introduction: TERFs, Gender-Critical Movements, and Postfascist Feminisms’. Transgender Studies Quarterly. 9(3) 311-333. https://doi.org/10.1215/23289252-9836008 Accessed 9 April 2024.
Brown, Lydia X.Z. 2016. ‘Gendervague: At the Intersection of Autism and Trans (repost)’. Autistic Hoya. 16 May 2020. https://www.autistichoya.com/2020/05/gendervague-at-intersection-of-autistic.html. Accessed 10 April 2024.
Butler, Judith. 2024. Who’s Afraid of Gender. London: Allen Lane
Cass, Hillary. 2024. The Cass Review: Final Report. https://cass.independent-review.uk/wp-content/uploads/2024/04/CassReview_Final.pdf
Cass, Hillary. 2022. The Cass Review: Interim Report. 2022. https://cass.independent-review.uk/wp-content/uploads/2022/03/Cass-Review-Interim-Report-Final-Web-Accessible.pdf Accessed 10 April 2024.
Chapman, Robert. 2023. Empire of Normality: Neurodiversity and Capitalism. London: Pluto Press.
Cooper, Kate, Mandy, William, Butler, Catherine., Russell, Ailsa. 2022. ‘Phenomenology of gender dysphoria in autism: a multiperspective qualitative analysis. 64(2) https://doi.org/10.1111/jcpp.13691 Accessed 10 April 2024.
Cooper, Kate., Mandy, William., Butler, Catherine., Russell, Alisa. 2021. ‘The lived experience of gender dysphoria in autistic adults: An interpretative phenomenological analysis’. Autism, 26(4). https://doi.org/10.1177/13623613211039113open_in_new Accessed 10 April 2024.
Elster, Mikey. 2022 ‘Insidious Concern: Trans Panic and the Limits of Care’, Transgender Studies Quarterly 9 (3) 407-424.
Frazer-Carroll, Micha. 2023. Mad World: The Politics of Mental Health. London: Pluto Press.
Gernsbacher and Yergeau. 2019. ‘Empirical Failures of the Claim that Autistic People Lack a Theory of Mind. Archives of Scientific Psychology. 7(1) 102-118. https://doi.org/10.1037/arc0000067 Accessed 10 April 2024.
Gratton, Finn V., Song, Minneh., Cooper, Kate., Kallitsounaki, Aimilia., Lai, Meng-Chuan., Lawson, Wenn., van der Miesen, Anna I.R.,Wimms, Harriette, E. 2023. ‘The Intersection of Autism and Transgender and Nonbinary Identities: Community and Academic Dialogue on Research and Advocacy’. Autism in Adulthood, 5(2). https://www.liebertpub.com/doi/10.1089/aut.2023.0042 Accessed 10 April 2024.
Guin, Kris. 2020. ‘Autistic, Trans, and Betrayed by J.K. Rowling’. Thinking Person’s Guide to Autism. https://thinkingautismguide.com/2020/06/autistic-trans-and-betrayed-by-jk-rowling.html Accessed 10 April 2024.
Jackson-Perry, David. 2021. ‘The Autistic Art of Failure? Unknowing Imperfect Systems of Sexuality and Gender. Scandinavian Journal of Disability Research, 22(1). 221-229 https://doi.org/10.16993/sjdr.634 Accessed 10 April 2024.
Johnson, Merri Lisa. 2021. ‘Neuroqueer Feminism: Turning with Tenderness toward Borderline Personality Disorder. Signs: Journal of Women in Culture and Society. 46(3) (2021) 635-62.
Lewis, Francesca. 2023. ‘The borderline as diagnostician: an autø/gnostic reading of a history of binaries’. Journal of Psychosocial Studies. 16(2). 104-116.
McGeer, Victoria. 2004. ‘Autistic Self-Awareness’. Philosophy, Psychiatry and Psychology. 11(3) 235-51.
Montgomery, C.B., Allison, C., Lai, M.C., Langdon, Peter E., and Baron-Cohen, Simon. ‘Do adults with high functioning autism or Asperger Syndrome differ in empathy and emotion recognition?’ Journal for Autism and Developmental Disorders. 46 (6) 1931-1940
Neumeier, Shain M. 2018. ‘“To Siri With Love” and the Problem with Neurodiversity Lite’. Rewire. 9 February. https://rewirenewsgroup.com/2018/02/09/siri-love-problem-neurodiversity-lite/ Accessed 10 April 2024
Raymaker, Dora. M. 2019. ‘Shifting the System: AASPIRE and the Loom of Science and Activism’. Autistic Community and the Neurodiversity Movement: Stories from the Frontline, ed by. Steven K. Kapp. Singapore: Palgrave Macmillan, pp. 133-45.
Rayner, Gordon. 2023. ‘Tavistock clinic ‘ignored’ link between autism and transgender children’. The Telegraph. 14 February. https://www.telegraph.co.uk/news/2023/02/14/tavistock-clinic-ignored-link-autism-transgender-children/ Accessed 10 April 2024
Rowling, J.K. 2020. ‘J.K. Rowling Writes about Her Reasons for Speaking out on Sex and Gender Issues’. J.K Rowling. 10 June. https://www.jkrowling.com/opinions/j-k-rowling-writes-about-her-reasons-for-speaking-out-on-sex-and-gender-issues/ Accessed 10 April 2024.
Walker, Nick. 2021. Neuroqueer Heresies: Notes on the Neurodiversity Paradigm, Autistic Empowerment and Postnormal Possibilities. Fort Worth, TX: Autonomous Press.
Yergeau, Remi. 2017. Authoring Autism: On Rhetoric and Neurological Queerness. Durham and London: Duke University Press.
