How child gender care is built on ‘shaky foundations’: Scathing report says ‘wholly inadequate’ data has ‘let down’ kids questioning their identity and rules there’s no evidence to support use of puberty blockers

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There is no good evidence supporting the use of puberty blockers and hormone treatments in transgender children, a damning review has found.

Gender medicine is ‘built on shaky foundations’ and largely relies on clinical guidelines that are not backed by science, report author Dr Hilary Cass warns.

The consultant paediatrician found doctors have failed to properly assess the short and long-term impact of treating confused kids, in an alarming departure from medical norms.

Calling for more rigorous research into the potential harms and benefits of social and clinical interventions, she described current data as ‘wholly inadequate’ and said youngsters have been ‘let down’.

Dr Cass, a former president of the Royal College of Paediatrics and Child Health, issued her chilling verdict after examining a series of studies she commissioned to inform her independent review of gender identity services for children and young people.

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

Dr Hilary Cass (pictured), a former president of the Royal College of Paediatrics and Child Health, issued her chilling verdict after examining a series of studies she commissioned to inform her independent review of gender identity services for children and young people

Dr Hilary Cass (pictured), a former president of the Royal College of Paediatrics and Child Health, issued her chilling verdict after examining a series of studies she commissioned to inform her independent review of gender identity services for children and young people 

Puberty blockers, known medically as gonadotrophin-releasing hormone analogues, stop the physical changes of puberty in teens questioning their gender. Pictured one example of these drugs, called Triptorelin

Puberty blockers, known medically as gonadotrophin-releasing hormone analogues, stop the physical changes of puberty in teens questioning their gender. Pictured one example of these drugs, called Triptorelin

Researchers from the University of York analysed dozens of existing studies into the use of puberty blockers and sex-swap hormones, as well as national and international guidelines on caring for children with gender-identity issues.

Of the 50 studies looking at the effectiveness of puberty blockers for gender questioning teens, only one was of high quality, with the others criticised for various flaws.

The researchers say most of the studies suggest treatment may weaken bones and stunt growth – but critically ‘no conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development’.

Similarly, of the 53 studies on the use of masculinising and feminising hormones, only one was of sufficiently high quality.

There was little or inconsistent evidence on key outcomes, such as body satisfaction, psychosocial and cognitive outcomes, fertility, bone health and cardiometabolic effects.

Writing in the medical journal Archives of Disease in Childhood, which published the academic studies to coincide with the release of the Cass Review, the researchers say: ‘Clinicians should ensure that adolescents considering hormone interventions are fully informed about the potential risk and benefits including side-effects, and the lack of high-quality evidence regarding these.’

Most of the 23 clinical guidelines – used by doctors when deciding how to treat children with gender issues – were found to lack independence or were not evidence-based.

The links between the evidence and the recommendations are often unclear, and largely informed by two international guidelines, which themselves lack scientific rigour, the authors warn.

Few recommend exploring sexual orientation or assessing body image, despite these being identified as important factors, and there are no recommendations for children who have started to transition but want to ‘detransition’.

Furthermore, there was no clear evidence that social transition in childhood has any positive or negative mental health outcomes, but ‘those who had socially transitioned at an earlier age and/or prior to being seen in clinic were more likely to proceed to a medical pathway’, the review said.

The experts write: ‘Published guidance recommends a care pathway for children and adolescents experiencing gender dysphoria/incongruence for which there is limited evidence about benefits and risks, and long-term effects.

‘Divergence of recommendations in recent guidelines suggest there is no current consensus about the purpose and process of assessment, or about when psychosocial care or hormonal interventions should be offered and on what basis.’

Addressing young people directly in her foreword, Dr Cass wrote: ‘I have been disappointed by the lack of evidence on the long-term impact of taking hormones from an early age; research has let us all down, most importantly you.’

Among the review’s recommendations are calls for NHS England to put a ‘full programme of research’ in place to analyse the characteristics and outcomes of every young person who uses gender services and for gender services to operate ‘to the same standards’ as other health services for children and young people.

Speaking to The BMJ, Dr Cass said there is no evidence to suggest that puberty blockers help children and young people ‘buy time to think’ or improve their psychological wellbeing.

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

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’

‘The only thing that we can tangibly say is that, particularly for the birth registered males, if you stop them breaking their voice and growing facial hair, then they may pass better [appear more female] in adulthood. But even that is not without qualification.’

She acknowledged that there was a point when ‘practice did deviate from the clinical evidence’ and adds ‘there unfortunately is no evidence that gender affirming treatment in its broadest sense, reduces suicide risk.’

Asked what she would say to children and young people, their families and carers, she replies: ‘We need to listen to them. We need to explain the weaknesses of the evidence.

‘But most importantly, we need to find ways to help them feel better about themselves so that they’re not going to be so distressed.’

Dr Cass said the guideline appraisals suggest the majority ‘have not followed the international standards for guideline development.’

She added: ‘Improving the evidence base for this population of young people is an essential next step.’

Revealed: Timeline of what has happened since the Cass report was commissioned nearly four years ago

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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