Cass review won’t please everyone, but raises hopes of better care for children
The Cass Review has been four years in the making, yet we did not have to wait for its final publication today before seeing the impact it will make.
Dr Hilary Cassâs interim findings, which were published in February 2022, led to the closure of the specialised gender identity development service (Gids) for children and adolescents, previously managed by a single provider â the Tavistock and Portman NHS foundation trust in London.
Last month, the Government announced children will no longer be prescribed controversial puberty blockers at the two gender identity clinics replacing Gids, which opened this month.
Dr Cass, a consultant paediatrician, has carried out a rigorous investigation and at some personal cost. As she acknowledges, the review was never going to please everyone, yet it treads a careful line and independent experts have praised her work.
The review ultimately confirms a fundamental shift in the treatment offered to children and adolescents who are questioning their gender, moving away from a medicalised approach and switching to a more holistic treatment pathway that will consider questions of gender alongside other possible issues in the childâs life.
The hope is that services should also become easier to access and will no longer be under a single provider.
At the heart of the review is the health and wellbeing of children â some 5,000 children and young people are on the waiting list for referral to the new clinics in the north and south of England â and Dr Cass is at pains to say in her forward that they have been let down.
However, now there is hope that those children can look forward to much better care in what will remain an extremely complex area of health.
Here are some key recommendations from the 32 made by Dr Hilary Cass:
Research
The NHS should put in place a âfull programme of researchâ looking at the characteristics, interventions and outcomes of every young person presenting to the NHS gender services, with consent routinely sought for enrolment in a research study which follows them into adulthood.
Gender care is âan area of remarkably weak evidenceâ, the review stated, but results of studies have been âexaggerated or misrepresented by people on all sides of the debate to support their viewpointâ.
Dr Cass said there is currently âno good evidence on the long-term outcomes of interventions to manage gender-related distressâ.
Care must be holistic
The care of children and young people questioning their gender identity or experiencing gender dysphoria âneeds to be holistic and personalâ.
Services âmust operate to the same standards as other services seeing children and young people with complex presentations and/or additional risk factorsâ.
Age
The approach to care for the youngest children should be different to that for teenagers.
There should be no lower age limit to accessing help and support and parents and families should be helped to ensure options âremain open and flexible for the childâ.
For those yet to hit puberty, there should be a âseparate pathwayâ of care within each regional network of services, and young children and their parents should be prioritised for âearly discussion with a professional with relevant experienceâ.
Approach to referrals
Referrals into the now-closed Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust were âunusualâ in that they were accepted directly from GPs and from non-healthcare professionals including teachers and youth workers.
Dr Cass said she supports the NHS England proposal for all referrals to come via secondary care.
Social transitioning
There was âno clear evidenceâ that social transition in childhood has any positive or negative mental health outcomes and ârelatively weakâ evidence for effects in adolescence.
But children who socially transitioned â changing names, pronouns etc â at an earlier age or before being seen in clinic âwere more likely to proceed to a medical pathwayâ.
Workforce
Professionals have been reluctant to engage in the clinical care of gender-questioning children and young people due to the weak evidence in the area, a lack of consistent professional guidance and support, and long-term implications of making the wrong judgment about treatment options, the review said.
There is a need for the âappropriate skill mix to support both individuals who require medical intervention and those who do notâ as work continues to increase the available workforce.
Detransition
NHS England should consider whether a separately commissioned service is needed for people who wish to detransition â where someone discontinues or reverses a medical gender transition â given that people who regret going through this process might be hesitant to return to the same service they had previously used.
The review states that âbetter services and pathwaysâ are needed for a group of whom many are âliving with the irreversible effects of transition and no clear way to access servicesâ.
Private healthcare
With puberty blockers no longer being prescribed to children on the NHS, the review stated that no GP should be expected to âenter into a shared care arrangement with a private providerâ if a young person has been given access to them via that route.
The review said GPs had âexpressed concern about being pressurised to prescribe hormones after these have been initiated by private providers and that there is a lack of clarity around their responsibilities in relation to monitoringâ.