From GPs being pressured to prescribe gender-questioning children powerful puberty-blockers to alarm over social transitioning, ALL the damning verdicts of the hugely-anticipated Cass Review

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Written By Rivera Claudia

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The independent review of gender services for children and young people was commissioned nearly four years ago.

An interim report was produced by Dr Hilary Cass, who led the review, in February 2022 – she has now published her final findings.

At nearly 400 pages, the review examined the challenges facing NHS England’s gender services for children and young people and made more than 30 recommendations.

These are some of the key themes Dr Cass’s report addressed…

An interim report was produced by Dr Hilary Cass (pictured), who led the review, in February 2022 – she has now published her final findings. At nearly 400 pages, the review examined the challenges facing NHS England’s gender services for children and young people and made more than 30 recommendations 

Keira Bell (pictured) took Tavistock and Portman NHS foundation trust to the High Court, claiming she had not been challenged enough, before being prescribed puberty blockers at just 16 called it 'a step in the right direction'

Keira Bell (pictured) took Tavistock and Portman NHS foundation trust to the High Court, claiming she had not been challenged enough, before being prescribed puberty blockers at just 16 called it ‘a step in the right direction’

TOXIC DEBATE

In her forward to the review Dr Cass warned ‘the toxicity of the debate is exceptional’.

She reported being criticised for engaging with all sides of the debate for her review which was so vicious ‘professionals are so afraid to openly discuss their views’.

Dr Cass said while there was little reliable evidence on trans-healthcare ‘results of studies are exaggerated or misrepresented by people on all sides of the debate’.

She issued a rallying cry to clinicians that ‘we have to cut through the noise and polarisation’ to provide trans-children with the same standard of care as others.

SCHOOLS

Dr Cass could only make recommendations for NHS England, with classrooms outside of her remit.

But the review sought to lay the groundwork for Government to introduce clearer guidelines of social transitioning in schools.

Dr Cass said ‘the importance of what happens in school cannot be under-estimated’, in a veiled reference to recent non-statutory guidance.

The systematic review found there was no clear evidence social transition had a positive or negative on a child’s mental health.

But it found those who socially transitioned ‘at an earlier age’ or before seeing a medical professional ‘were more likely to proceed to a medical pathway’.

It also issued a warning to those seeking to exclude parents stating they ‘should be actively involved in decision making unless there are strong grounds to believe that this may put the child or young person at risk’.

PRIVATE CLINICS

The review found that young people had been driven to private providers having sat on the NHS waiting list.

Focus groups told Cass they felt there was a ‘forced choice’ to use private clinics as NHS provision took too long to access.

Dr Cass also said she was concerned over the use of unregulated medications by ‘providers that are not regulated within the UK’.

She had been told GPs were concerned they had been ‘pressurised to prescribe hormones after these have been initiated by private providers’.

But the review concluded GPs should not ‘be expected to enter into a shared care arrangement provider, particularly if that private provider is acting outside NHS guidance’.

Retired consultant paediatrician Dr Cass speaking about the publication of the Independent Review of Gender Identity Services for Children and Young People, April 9

Retired consultant paediatrician Dr Cass speaking about the publication of the Independent Review of Gender Identity Services for Children and Young People, April 9

The former president of the Royal College of Paediatrics and Child Health was appointed to lead the Independent Review of Gender Identity Services for Children and Young People in 2020

The former president of the Royal College of Paediatrics and Child Health was appointed to lead the Independent Review of Gender Identity Services for Children and Young People in 2020

GEN Z

A large amount of work went into understanding the characteristics of trans-children and young people.

The review found Generation Z and some younger Millennials had different beliefs about the fluidity of gender, compared to older generations.

It cited a US survey which showed Gen Z adults were the first generation to respond negatively to the statement ‘there are only two genders’.

The survey found the attitudes had changed quickly – within a six-month period between early 2020 and late 2020-early 2021.

Dr Cass’s forward also referenced those who identified as non-binary, describing it as ‘the fastest growing group identifying under the trans umbrella’.

in a sign of changes being underway, the NHS's old Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust shut its doors two weeks ago

in a sign of changes being underway, the NHS’s old Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust shut its doors two weeks ago

TRAUMATIC EXPERIENCES

The systematic review found there was little research on ‘adverse childhood experiences’. But the studies they did find showed high rates among children referred to gender services.

They found between 11 to 67 per cent had suffered combined neglect or abuse; 15-20 per cent had been physically abused; 5-19 per cent sexually abused; and 14 per cent emotionally abused.

Traumatic experiences to family members were also a contributing factor, with maternal mental illness or substance abuse cited in between 53 per cent and 49 per cent of cases respectively.

Paternal mental illness or substance abuse was found to exist in 38 per cent of cases.

THE CASS REPORT TIMELINE 

Here is a timeline of events since it the Cass report was launched almost four years ago.

2020

September: The Independent Review of Gender Identity Services for Children and Young People is commissioned by NHS England and NHS Improvement to make recommendations about NHS services for gender-questioning children and young people.

Led by Dr Hilary Cass, former president of the Royal College of Paediatrics and Child Health, it is known as the Cass Review.

NHS England says it has been established ‘in response to a complex and diverse range of issues’ including the significant rise in referrals to the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust from just under 250 in 2011/12 to more than 5,000 in 2021/22.

October and November: The Care Quality Commission (CQC) inspects GIDS, which is the only service available in England for children and young people with gender dysphoria, also treating children and young people from Wales.

2021

January: The CQC publishes its inspection report which rates the service inadequate overall.

The watchdog says the service is difficult to access, with young people waiting more than two years for their first appointment, and that staff do not develop holistic care plans for patients, with ‘significant variations in the clinical approach of professionals’ and no clarity in records on why decisions had been made.

2022

March: Dr Cass publishes her interim report, saying a ‘fundamentally different service model is needed which is more in line with other paediatric provision’, and concluding that a sole provider of such services is ‘not a safe or viable long-term option’.

July: The NHS announces GIDS will close and be replaced with a regional network, aimed to be up and running by spring 2023.

2023

The deadline for the regional clinics to be operating is pushed back amid what NHS England describes as the ‘complex’ set-up of the ‘completely new service’. The new aim is spring 2024.

2024

March: NHS England confirms children will no longer be prescribed puberty blockers at gender identity clinics, saying there is not enough evidence to support their ‘safety or clinical effectiveness” and that they would only be available to children as part of clinical research trials.

April: New regional hubs open as the GIDS at Tavistock officially closes.

Led by London’s Great Ormond Street Hospital and Alder Hey Children’s Hospital in Liverpool, NHS England hopes they will be the first of up to eight specialist centres as part of the north and south hubs over the next two years.

The Cass Review’s final report is published.

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Exposure to domestic violence was present in between 23-25 per cent of cases and death or permanent hospitalisation of a parent in 8 per cent to 19 per cent of cases.

While the data had limitations a review of the first 124 cases at the NHS Gender Identity Development Service (Gids) found over a quarter of all referrals had spent some time in care.

Nearly half of all referrals had experienced living with only one parent.

DE-TRANSITIONING

One of Cass’s recommendations was people thinking about de-transitioning should be cared for by a separate service.

She noted NHS England should recognise ‘they may not wish to reengage with the services whose care they were previously under’.

The recommendation had been informed by experiences of people who told the review they regretted transitioning.

It found they may ‘be hesitant to engage with the gender services that supported them through their initial transition’.

Perhaps the most high profile case of de-transitioning is that of Keira Bell.

She began taking puberty blockers at 16-years-old before transitioning to a male – she has said in the past the Tavistock clinic should have done more to challenge her.

LACK OF CO-OPERATION

The Cass review published a series of appendices, including an exchange of letters between Dr Cass and John Stewart the national director for special commissioning at NHS England.

He manages the 150 specialised services directly commissioned by NHS England’s national and regional teams.

In January this year (2024) Mr Stewart wrote to Dr Cass over the research programme, led by the University of York. The goal was to track the experiences of patients at Gids and NHS adult gender clinics.

But it transpired the researchers’ efforts was scuppered because ‘the necessary cooperation from the clinical leads within those services has not been forthcoming’.

He described the refusal by clinicians as ‘clearly very disappointing and if left this way would represent a missed opportunity for the NHS’.

WPATH guidelines

Some of the fiercest criticism in Cass’s review was reserved for the World Professional Association of Transgender Health and the ‘Standards of Care’ it produced.

Cass concluded WPATH had been ‘highly influential’ on shaping what was considered international best practice but the University of York reviewers found it ‘to lack developmental rigour’.

By tracing a number of international guidelines the reviewers found WPATH’s ‘Standards of Care 7’ and an Endocrine Society guideline, ‘influenced nearly all the other[s]’.

The reviewers also found that WPATH’s ‘Standards of Care 8’ then went on to cite those other guidelines to justify its latest recommendations, despite ‘having been considerably influenced by WPATH 7’.

The review concluded: ‘The circularity of this approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.’

PUBERTY BLOCKERS

The University of York was commissioned to conduct a systematic review of puberty blockers and cross-sex hormones.

It found multiple studies showed puberty blockers fulfilled their purpose in pausing physical changes but also compromised bone density.

But the reviewers concluded puberty blockers did not change a patient’s body dissatisfaction or gender dysphoria.

There was no evidence to show puberty blockers ‘buy time to think’ for trans-children to decide on their continued treatment.

The reviewers voiced concern treatment ‘may change the trajectory of psychosexual and gender identity development’.

There was a lack of high-quality evidence on cross-sex hormones with reviewers unable to draw any conclusions.

They said claims cross-sex hormones helped reduce suicide risks were not borne out by the evidence.

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