What did the review into gender services find? 

Welcome to Wednesday’s Early Edition from i.

The “exceptionally toxic” debate around transgender healthcare must end, the retired paediatrician who led a four-year review into the services has urged. In her long-awaited nearly 400-page report, Dr Hilary Cass said: “Polarisation and stifling of debate do nothing to help the young people caught in the middle of a stormy social discourse, and in the long run will also hamper the research that is essential to finding the best way of supporting them to thrive.” Her review was set up in September 2020 in response to what NHS England said “was a complex and diverse range of issues” including the rise in referrals to the Gender Identity Development Service from just under 250 to more than 5,000 over a ten-year period. Dr Cass insisted the review is “not about defining what it means to be trans, nor is it about undermining the validity of trans identities, challenging the right of people to express themselves, or rolling back on people’s rights to healthcare”. So what are its findings, and has it already had an impact? We’ll take a look, after the headlines.

 Today’s news, and why it matters

 More than seven million people across the UK are struggling with the cost of living crisis, as inflation and high interest rates hinder their efforts to make ends meet. A survey found an estimated 7.4 million people reported feeling heavily burdened keeping up with domestic bills and credit repayments at the start of this year.

Whoever wins the next election is going to face a series of deeply unpalatable choices on public spending amid warnings that on the current trajectory, unprotected Government departments face cuts of £20bn. A ‘particularly tricky in-tray’ of one-off and unavoidable costs awaits the winner of the general election, according to the IFS.

Campaigner Alan Bates said the Post Office is an “atrocious organisation” and “needs disbanding” during his appearance at the public inquiry into the Horizon scandal. “The whole of the postal service nowadays – it’s a dead duck. It’s beyond saving,” he told the inquiry. Here’s six things we learned.

The UK’s biggest rail factory will be “lost” forever together with thousands of jobs unless it receives an immediate order for just 10 more trains, its boss has warned. The 147-year-old Alstom factory in Derby is already winding down after 11 months of “frustrating” talks with the Government, according to the French firm’s UK managing director Nick Crossfield.

The Home Office is under pressure to clarify who will operate flights to Rwanda if the Government’s flagship plan to deport asylum seekers to the African country goes ahead. Rishi Sunak hosted Rwandan President Paul Kagame at Downing Street on Tuesday, amid reports that ministers are struggling to reach a deal with an airline to transport migrants to Kigali under the proposed scheme.

The Nobel Prize-winning physicist behind the concept of the subatomic Higgs boson particle, Professor Peter Higgs, has died aged 94. Professor Higgs predicted the existence of a so-called “god particle”- which helped explain how matter formed after the Big Bang – in 1964.

A powerful animal tranquiliser known as “tranq dope” has “penetrated” the UK’s illegal drug market, experts have warned. Xylazine, also known as “tranq” or “the zombie drug”, has been found in counterfeit prescription medication tablets, THC (tetrahydrocannabinol) vapes and cocaine.

Three questions on the Cass review:

What were the recommendations? Among the most headline-grabbing findings of the report were that the NHS should review its policy on giving children masculinising or feminising hormones from the age of 16. While puberty blockers are no longer be given to children outside research trials as of last month, 16-year-olds can still be given hormones in the form of testosterone or oestrogen. Dr Hilary Cass said this should only be done with “extreme caution” and that there should be “a clear clinical rationale” for providing hormones to a child rather than waiting until they reach 18. She said: “For most young people, a medical pathway will not be the best way to manage their gender-related distress. For those young people for whom a medical pathway is clinically indicated, it is not enough to provide this without also addressing wider mental health and/or psychosocially challenging problems.” The Cass Review also said young people aged 17-25 should have a “follow-through” service for care instead of going straight into adult services “to ensure continuity of care and support at a potentially vulnerable stage in their journey”. It also said young people aged 17-25 should have a “follow-through” service for care instead of going straight into adult services “to ensure continuity of care and support at a potentially vulnerable stage in their journey”. The report warned a “more cautious approach” must be taken for children than for adolescents when it comes to social transitioning, which is where someone might change their pronouns, name or clothing. The review also found that the majority of guidelines for managing children with gender dysphoria or incongruence “lacks an independent and evidence-based approach and information about how recommendations were developed”. Dr Cass said “the majority of clinical guidelines have not followed the international standards for guideline development.” The review calls for more research, “holistic and personal” and age appropriate care of children, and the consideration of a separately commissioned service for people who wish to detransition. Read more here.

Will it lead to better care? As i‘s Paul Gallagher writes: “At the heart of the review is the health and wellbeing of children – around 5,000 children and young people are on the waiting list for referral to the new clinics in the north and south of England – and Dr Cass is at pains to say in her foreword 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.” Read his piece here. However the report has already received criticism. A mother of a trans child told the Guardian the review represented “an agenda from up on high that things need to be more difficult”. She said: “It’s hard enough as a parent without having the entire society or media pointing at transgender people as if they’re some aberration or as if they threaten us.” Dr Aidan Kelly, a clinical psychologist specialising in gender who left the Tavistock clinic in 2021, also told the paper NHS England’s stance on puberty blockers had left it “out of step with the rest of the world”.

Has it already had an impact? It didn’t take the final publication of the report for an impact on gender identity services in the country to be made. A number of changes to gender healthcare have been implemented since the review began four years ago. The interim findings, published in early 2022, led to the closure of the Gids service at the Tavistock and Portman foundation trust in London. That report said the number of children seeking NHS help “is now outstripping the capacity of the single national specialist service” and there was a need to move away from the model of a sole provider. In March 2022, Dr Cass wrote: “It has become increasingly clear that a single specialist provider model is not a safe or viable long-term option in view of concerns about lack of peer review and the ability to respond to the increasing demand.” At the time, the NHS said it intends to build a “more resilient service” by expanding provision into a regional network and to establish two services led by specialist children’s hospitals in London and the North West. However whistleblowers recently told i the new clinics for young people are “nowhere near ready”, “understaffed”, and employing inexperienced clinicians who don’t have a finished treatment protocol in place. “It’s been shoddy, disorganised, messy and unclear. And at times, it’s felt unsafe,” said one. “They’re not fully staffed, they’re not fully trained.” It’s like “reinventing the wheel with a square,” said another. “We’re going from a single-service model to a no-service model,” said a third. Staffing levels at the hubs are of particular concern to those who spoke with i. One said: “They have 17 or 18 clinical staff in total across both clinics. When GIDS was operating at its peak we had 70-plus clinicians.” Read that story here. Dr Cass’ interim report also pointed to a lack of long-term evidence and data collection on what happens to children and young people who are prescribed medication. At the time she said Gids had not collected routine and consistent data “which means it is not possible to accurately track the outcomes and pathways that children and young people take through the service.” Last month the NHS confirmed that children will no longer be prescribed puberty blockers at gender identity clinics in England.

Around the world

 Hamas is unable to deliver 40 living hostages for the first phase of a prospective prisoner exchange deal with Israel, according to reports, raising fears more have died in captivity than thought. Israel says that 133 hostages are still being held in Gaza more than six months into the war, with dozens thought to be dead.

Russia’s advances in eastern Ukraine could be slowed by rocketing equipment losses that military experts believe are “unsustainable”. Western officials have warned that Ukraine could lose more territory without an increase in western military aid to counter Russia’s advantage in equipment and manpower, as frontline cities including Chasiv Yar and Kharkiv come under bombardment.

The judge presiding over Donald Trump’s upcoming hush money trial has drawn up a list of 42 questions for jurors, covering everything from the social media channels they follow, to whether they belong to extremist groups, to their views on the former president’s treatment. Experts believe Judge Juan Merchan is taking “extreme steps” to investigate potential jurors’ interests and background in a bid to make sure the case is not prejudiced.

Men will soon be allowed to enter a women’s-only artwork in Australia, following a high-stakes court case over the matter. The Ladies Lounge exhibit at Tasmania’s Museum of Old and New Art (Mona) sought to highlight historic misogyny by banning male visitors.

 Watch out for…

 Lord Cameron, who continues meetings in Washington today and is expected to appear on US TV networks including CNN and Fox News this afternoon. 

 Thoughts for the day

 Trump meeting shows off Cameron’s power – and poses a tricky question for Labour. Lord Cameron and his team recognise Trump’s hold over the rest of the Republican Party, writes Kate McCann.

The cruellest benefits crackdown we’ve seen yet. Carers are not tax dodgers or benefit fraudsters,

says Andrew Fisher.

Quibbling about the Hardest Geezer’s achievement completely misses the point. Why all the nitpicking, asks Alex Dakers.

Culture Break

 Star trumpeter Alison Balsom: ‘We don’t need to save classical music – it needs to save us’. The musician is thrilled to be a role model – but she’s extremely concerned that today’s children aren’t even getting the chance to try out various instruments.

 The Big Read

 The Keir Starmer powerbroker who is Labour’s ‘anti-Dominic Cummings’. Pat McFadden – ‘the most influential MP you’ve never heard of’ – prefers calm reason to rage and may soon wield more power than ever, reports Rachel Wearmouth.

Sport

 Everton’s second FFP breach could spark vicious cycle of clubs suing each other. Everton face the threat of legal action from rivals for breaching financial rules on two separate occasions, a leading sports lawyer tells i

 Something to brighten your day

 I tried the Danish art of doing nothing and realised how much of life passes me by. Is it possible to do absolutely nothing outside work? Kia-Elise Green spends a week trying out the Danish practice of ‘Niksen’.