Not the First, Not the Last: How Institutions Manufacture Legitimacy Through Expert-Led Containment
Dr Hilary Cass is not a rogue figure. She is the latest in a long line of carefully selected experts deployed to manage dissent, sanitise state anxieties, and neutralise calls for justice.
The Cass Review isn’t an outlier—it’s part of a systemic pattern. This piece traces how institutions use expert-led reports to contain dissent, marginalise lived experience, and reward compliance with power.
Introduction
The Cass Review has drawn extensive scrutiny, most notably from Noone et al. (2025), whose peer-reviewed analysis laid bare the methodological failures underpinning its conclusions. But whilst the report itself is deeply flawed, the real story lies not in the errors of a single document, but in the machinery that produced it. Dr. Hilary Cass is not an outlier. She is a type—carefully selected for her credentials, institutional credibility, and clinical detachment. She represents a reliable pattern: the deployment of professional authority not to illuminate truth, but to stabilise narratives already favoured by those in power. This article is not just a critique of the Cass Review; it is a pattern recognition exercise. It draws from forensic science, education policy, and disability justice to expose how institutions routinely select, shape, and reward figures like Cass—not despite their distance from the communities affected, but because of it. The goal is not inquiry, but containment. And Cass, like many before her, was chosen not to resolve uncertainty, but to absorb and redirect it—channelling systemic discomfort into expert-led reassurance that maintains the status quo.
The Cass Review as a Case Study in Manufactured Neutrality
The Cass Review positioned itself as an independent, evidence-based evaluation of NHS gender identity services for young people in England and Wales. Commissioned in 2020, it was launched amidst growing public and political anxiety around trans youth, fuelled by a hostile media climate, legal challenges, and rising anti-trans sentiment. Framed as a neutral inquiry, the review ultimately recommended a more cautious approach to medical transition for under-18s, including the indefinite suspension of puberty blockers outside of research settings. These conclusions have since been used to justify policy changes not only in the UK but also abroad, aligning with broader international efforts to restrict access to gender-affirming care. In the United States, the Cass Review has already been cited in court cases and legislative debates as evidence that such care is unproven or unsafe.
However, the credibility of the Cass Review has been systematically dismantled by Noone et al. (2025), whose rigorous peer-reviewed critique exposes deep methodological flaws. Among the most significant concerns is the misuse of the GRADE framework—an evaluative tool designed for clinical trials, not the complex mix of observational, longitudinal, and qualitative research that characterises gender care studies. Cass’s team applied GRADE inappropriately, leading to the wholesale downgrading of large portions of the evidence base. In addition, the review excluded nearly half of the available studies, particularly those not in English or outside of high-income settings, introducing cultural and linguistic bias into what was presented as a universal conclusion. Noone et al. also noted the selective use of quotations from trans youth, in some cases excerpted out of context to imply doubt or instability where the full source material indicated affirmation and clarity.
What makes this all the more alarming is the timing of an honour conferred on Dr. Cass. Just months after the publication of her final report, she was appointed as a life peer in the House of Lords. Whilst presented as recognition for her contributions to paediatrics, the political symbolism is hard to ignore. The elevation of Cass to legislative authority, directly following a report that aligned so closely with the government’s preferred stance, illustrates how “evidence-based neutrality” can function as a cover for ideological alignment. This is not just about flawed science—it’s about how flawed science is rewarded when it serves power.
Cass as a Reproducible Figure: The Function of the Manufactured Expert
Dr. Cass exemplifies a particular institutional archetype—one that recurs across disciplines, policy reviews, and public crises. She is what the American legal system might call a “liar for hire,” though in her case the role is performed not through overt dishonesty, but through the quiet alchemy of clinical detachment and bureaucratic fluency. This figure—a credentialed professional, external to the community in question, trained in systems-based interventionism—is repeatedly selected to deliver conclusions that appear neutral, whilst ultimately reinforcing state or institutional interests. The manufactured expert does not need to distort the data. The framing does that for them.
What makes Cass so effective in this role is not just her expertise in paediatrics, but the kind of expertise she embodies. Her background is steeped in the medical model: diagnostic hierarchies, risk management, and procedural care. There is no space within this framework for lived experience, relational autonomy, or non-linear understandings of identity. Her authority derives not from proximity to trans or neurodivergent lives, but from her clinical distance from them. And it is that very distance which institutions prize—because it enables them to present containment as caution, and restriction as reasoned deliberation.
The archetype is consistent across domains. These figures tend to share a similar professional profile: clinical or forensic training, often with a history of high-level institutional roles. They are deeply embedded in systems that reward procedural fidelity over relational accountability. Their perceived neutrality is in fact a function of their removal—from activism, from identity politics, from the communities most affected by their decisions. This cultivated distance allows them to be framed as “above the fray,” even as their work is used to enact political agendas.
Language plays a crucial role here. Manufactured experts often deploy the rhetoric of scientific prudence—speaking of “insufficient evidence,” “emerging consensus,” or “safe pathways” whilst quietly narrowing what counts as legitimate data. Terms like “holistic care” and “clinical oversight” sound benign, even progressive, until one examines how they’re operationalised: often as delays, denials, and new gatekeeping thresholds. In such contexts, neutrality is not the absence of bias—it is the performance of it.
Dr. Cass did not create this template, nor is she the only one to occupy it. But she fits it with alarming precision. She was chosen not despite her detachment from the communities affected, but because of it. Her report, like many before it, cloaks its political function in professional language. In doing so, it offers institutions the appearance of scientific integrity while preserving the very systems those institutions are invested in maintaining.
The Pattern: From Crisis to Containment
This is a story we’ve seen many times before. A familiar institutional playbook, unfolding with unnerving regularity. First, a crisis—or more accurately, a perceived crisis—emerges. It might be rising numbers of young people identifying as trans, a moral panic over reading proficiency in schools, or forensic failures exposed by wrongful convictions. The underlying dynamics are often complex, rooted in social inequality, systemic neglect, or evolving cultural understanding. But institutions, particularly those tethered to state power, are less interested in reckoning with complexity than in managing it. And so begins the containment cycle.
The next step is the commissioning of a “neutral” inquiry. The choice of lead is never accidental. It is someone institutionally trusted, professionally credentialed, and most importantly, distanced from the communities at the centre of the concern. In the case of trans youth, it was Dr. Hilary Cass. In education, it might be a former chief inspector or a literacy “czar.” In forensics, a senior figure tied to a lab or law enforcement agency. The person must appear impartial whilst carrying the authority to reassert control.
The resulting report rarely addresses the structural roots of the crisis. Instead, it reframes the issue as a technical problem—something that can be managed through new guidelines, revised protocols, or “balanced” approaches. The language is careful, measured, and ostensibly reasonable. But what’s missing is just as telling: the lived experiences of those most affected, the historical context, the patterns of exclusion that predate the crisis itself. In this way, the report doesn't challenge the system. It reinscribes it.
Policy follows swiftly. Despite the methodological flaws or limited scope of such reviews, their findings are treated as definitive. Cass’s recommendations were implemented with astonishing speed, leading to a near-total cessation of puberty blocker access for trans youth in the UK. Similar processes have played out in education, criminal justice, and disability services. The reports become law-like—sheltering policymakers from accountability behind the shield of “evidence-based” governance.
And then, the reward. The expert is elevated—granted a peerage, appointed to a board, offered a platform in the media. Their compliance with institutional aims is repackaged as professional excellence. Meanwhile, those who challenge the findings—trans advocates, neurodivergent scholars, grassroots researchers—are dismissed not on the strength of their arguments but through the discrediting label of “activism.” In this cycle, dissent is not debated. It is sidelined.
This is not reform. It is a mechanism of containment. The report is not an end—it is a tool. And the pattern continues, precisely because it works.
Precedents Across Sectors
The Cass Review does not exist in isolation. It sits within a well-worn tradition of reviews, reports, and inquiries across sectors that adopt a posture of neutrality while embedding practices of exclusion, containment, or harm. These precedents show how flawed or selectively interpreted science can become the basis for policy, regulation, or courtroom procedure—often without adequate challenge, and with consequences that reverberate for years.
In forensic science, this pattern is particularly stark. A 2018 article by Meline and Bruehs, published in the Journal of Forensic Identification, compared reverse projection and laser scanning photogrammetry for height estimation from CCTV footage. On the surface, it appeared to offer a rigorous comparative analysis. In reality, as I noted in two letters to the editor (Hoerricks, 2019a, 2019b), the study lacked basic methodological integrity. The equipment was poorly specified, the software was used outside of manufacturer-supported parameters, and no test–retest validation or IRB approval was documented—despite the use of human subjects. Citations were misapplied, sometimes directly contradicting the claims to which they were attached. Yet, the article was published and remains widely cited.
Subsequent research has accepted its premise uncritically. Studies by Epstein and Westlake (2019), Olver et al. (2021), Liscio et al. (2021), and Flight and Ballantyne (2022) all build on or compare methodologies grounded in the Meline and Bruehs study. Many of these papers serve commercial interests—validating proprietary software or techniques for courtroom use. The original publication thus becomes a cornerstone, legitimising a chain of forensic practices whose scientific foundation is, at best, unstable. And there is no systematic way to track how many times this flawed foundation has been cited in courtrooms—where the stakes are liberty, credibility, and justice itself.
Education policy offers a parallel terrain. In the UK and beyond, national reading panels and SEND (Special Educational Needs and Disabilities) reviews have been framed as rigorous assessments of best practice. Yet these too often mask political agendas. The “Science of Reading” movement, for instance, presents itself as grounded in cognitive neuroscience, but in practice narrows literacy instruction to phonics-heavy models that marginalise multilingual learners, neurodivergent students, and those with complex educational histories. Reviews into SEND provision claim to address systemic barriers but routinely sidestep austerity, racialised tracking, or the coercive power of behaviourist interventions in the lives of disabled children.
Even in child protection and criminal justice, the pattern holds. Reviews such as Munro (child safeguarding), Bichard (information-sharing after the Soham murders), and Macpherson (institutional racism in the Met Police) each began with an urgent call for reform. Yet in their implementation, their findings were distilled into technical solutions—more data, more surveillance, more managerial oversight—rather than structural accountability. Over time, these reports came to serve the very systems they initially sought to critique.
Across each of these sectors, we see the same arc: a perceived problem, a report framed as impartial, a set of recommendations that entrench rather than unsettle, and a wave of uncritical uptake. The Cass Review is simply the latest iteration—a familiar shape in a long-established pattern.
Why This Pattern Endures
This pattern endures not because it is invisible, but because it is effective—deeply suited to the needs of institutions that prioritise stability over transformation. Reviews like Cass’s offer a well-worn solution to systemic discomfort: a performance of listening, followed by a restatement of control. In this way, expert-led inquiries serve as a kind of institutional reflex. They absorb public pressure, give the appearance of action, and deliver outcomes that leave the underlying structures intact.
The state, and the systems aligned with it, are not neutral actors. They are invested in managing dissent, not dismantling the hierarchies that produce it. When demands for justice—whether from trans communities, neurodivergent students, or racialised families navigating the care system—become too loud to ignore, the response is rarely to invite those voices into decision-making. Instead, it is to commission a review. The review must appear responsive, even generous in its scope. But the outcome is carefully shaped: by who leads it, what questions are asked, and—just as importantly—what kinds of knowledge are excluded.
Lived experience, community-led research, and intersectional analysis rarely make it past the first gate. These ways of knowing are often framed as “biased,” “anecdotal,” or “activist”—as though objectivity can only exist in clinical detachment, and as though the harms being described are somehow less real because they have not been captured in the language of institutional science. In practice, this means that the people most affected by policy decisions are the least likely to be understood on their own terms. Their insights are not treated as data; they are treated as noise.
This is how the cycle sustains itself. The review becomes a buffer—between power and the people it harms. It defers action whilst appearing decisive. It offers professional reassurance while sidestepping collective accountability. It produces reports that are cited as evidence, even when their foundations are flawed or their implications harmful. And when all is done, it installs the reviewer—now a public authority on the matter—as a gatekeeper for the future.
The endurance of this model is not accidental. It is the outcome of design. A design that privileges manageability over justice, reputation over repair, and professional distance over relational truth. So long as the purpose of review is to preserve power, the review will continue to serve that power well.
Autistic GLP Insight as Resistance
For me, as an autistic gestalt language processor, the Cass Review was never just about evidence or its absence. From the outset, I could sense the shape of it—long before the Noone et al. critique arrived to confirm the technical failures. Gestalt processing doesn’t work in straight lines. It moves relationally, associatively, noticing echoes between systems that others might treat as discrete. Where neurotypical reasoning often privileges linear causality—this leads to that—I process in constellations. I don’t just see the conclusions. I see the choreography.
This is why the Cass Review felt so familiar. Not because I’d read another report just like it, but because I recognised the pattern. The language of neutrality. The omission of lived experience. The credentialed voice speaking on behalf of those it has never met. The review that stabilises rather than disrupts. I’ve seen it in forensic science, in SEND reviews, in behavioural policies that claim to support but instead surveil. Cass was not surprising. She was legible from the beginning—as a product of the system, not an exception to it.
That doesn’t undermine the importance of what Noone et al. achieved. Their critique is meticulous, detailed, and essential. It dissects the methodological scaffolding of the review and shows precisely where it collapses under scrutiny. But my knowing came differently. It arrived not through the failure of the citations, but through the alignment of the report’s structure with countless others I’ve encountered before. That’s what gestalt language processing enables—a form of insight that is both pattern-driven and emotionally attuned. It recognises when something is off before it can be named.
Neurodivergent ways of knowing are often treated as secondary—intuitive, imprecise, or overly emotional. But they are nothing of the sort. These ways of knowing are rigorous, embodied, and profoundly relational. They are particularly suited to exposing systems that operate through repetition, impression management, and the manipulation of trust. Our minds are often drawn to what is unspoken, to what loops back, to what doesn’t quite fit. That’s not a flaw. It’s resistance.
To perceive the pattern is not to disengage from critique—it is to deepen it. My way of thinking doesn’t just ask what the Cass Review said or what it got wrong. It asks: Why this review? Why now? And what does it serve? In a world where institutions rely on our confusion, neurodivergent clarity is not just valid. It’s vital.
Final thoughts …
Dr. Hilary Cass is not the first to occupy this role, and she will not be the last. The apparatus that selected her, shaped the scope of her review, and rewarded her with a life peerage is not unique to gender healthcare, nor to the UK. It is a recurring structure, reappearing across fields wherever marginalised communities challenge the state’s preferred narratives. If we focus only on the individual report—on Cass as a person—we miss the deeper truth. This is not a failure of expertise. It is the function of expertise, as defined by institutions that seek control, not transformation.
To disrupt this cycle, we must learn to recognise the pattern: the reliable emergence of the ‘neutral’ expert; the reframing of systemic harm as clinical uncertainty; the swift adoption of policies that reduce care to management; the dismissal of dissent as unscientific or hysterical. These are not incidental. They are structural. The review is not evidence of impartial inquiry—it is often evidence of institutional self-preservation, draped in the language of science.
Naming the pattern is the first act of resistance. It creates space to imagine something different—ways of knowing and acting that are rooted not in the cold detachment of procedural expertise, but in the warmth and complexity of lived experience. That kind of knowledge does not require approval from institutional gatekeepers. It is found in the testimony of trans youth navigating care, in the grassroots researchers building alternative models, in the disabled communities refusing the logic of deficit. It is found in the links we make between seemingly unrelated reports, inquiries, and disciplines—and in the understanding that they all form part of the same machinery.
The task now is to build counter-narratives. Narratives that centre community accountability, relational ethics, and intersectional solidarity. Narratives that refuse the seduction of respectability when it comes at the cost of truth. Because if we do not name how these systems work, they will continue to reproduce themselves, choosing the next Cass, the next report, the next expertly sanctioned act of harm. But if we name it—clearly, collectively, and unapologetically—we begin to break the spell. And in that rupture, something new becomes possible.