Hilary Cass: Ideology on all sides directed gender care of children

NHS adult gender services in England will undergo a major review after the doctor behind a long-awaited report on children’s services said teenagers are “falling off a cliff edge” in their care when they reach 17.

The announcement came as the Cass Review’s final report said children have been let down by a lack of research and evidence on medical interventions in gender care, in a debate which it said has become exceptionally toxic.

Welcoming the review, Prime Minister Rishi Sunak said: “The wellbeing and health of children must come first.”

Among the 32 recommendations in the near-400 page report, the independent review of gender identity services for children and young people said a “follow-through service” should be put in place for 17-25-year-olds, with regional centres either extending the age range of their patients or through “linked services”.

Responding to the report, NHS England said it had written to local NHS leaders to pause first appointment offers at adult gender clinics to young people before their 18th birthday, and is “bringing forward its systemic review of adult gender services”.

In a letter to Dr Cass, officials said that review will now “be undertaken in the context of a broader, systemic review of the operation and delivery of the GDCs (gender dysphoria clinics)”.

NHS England said it will provide detail “very soon” but it is understood it will be a Cass-style review led by an independent expert.

Dr Cass, in her report which said gender care is an area of “remarkably weak evidence” and young people have been caught up in a “stormy social discourse”, welcomed the news.

She said it was “good to hear that they are taking note of our recommendation”, adding that adult services are now predominantly seeing under-25s who have “significant complexity”, and deserve to have “the breadth of their needs” addressed.

She said: “We are worried particularly about the vulnerable group around 17 who are falling off a cliff edge really between services.”

Her report, first commissioned in 2020 and published on Wednesday, called for gender services to operate “to the same standards” as other health services for children and young people, with “a holistic assessment” of people referred, including screening for neurodevelopmental conditions such as autism, and a mental health assessment.

Dr Cass said: “I think it’s definitely the case that ideology on all sides has directed care, rather than care being directed by normal principles of paediatrics and mental health.

“I mean, certainly professionals are afraid to do the things that they would normally do in any other consultation with a young person, and that can’t be right.”

Her report urged a review of the current policy on giving children masculinising or feminising hormones in the form of testosterone or oestrogen from the age of 16, urging “extreme caution”.

NHS England said it has agreed to this recommendation.

Dr Cass, a retired consultant paediatrician, said there “should be a clear clinical rationale” for giving hormones before someone turns 18.

All young people using gender services should be asked to be part of research, she added, in a bid to build a better picture of the long-term outcomes for patients.

Research by the University of York carried out alongside the report found evidence to be severely lacking on the impact of puberty blockers and hormone treatments, while the majority of clinical guidelines were found not to have followed international standards.

Dr Cass said it was “extremely disappointing” to find World Professional Association of Transgender Healthcare (WPATH) guidelines which were taken as an industry standard and adopted very widely internationally, “were very, very poorly evidence-based”.

She said she believes the review has “certainly brought forward an international conversation, which is so important, because one of the real problems in this area is the difficulty in trying to get a conversation that’s not toxic and that’s not very polarised”.

Sharing her personal experience, she said she had faced criticism for engaging with groups on all sides of the debate, and described having come into contact with some “very aggressive people” during meetings as part of her work, seen negative comments online, and had people who “emailed in critically”.

While there was “no clear evidence” that social transition – such as changing names and pronouns – in childhood has any positive or negative mental health outcomes, the review said a “more cautious approach” should be taken for young children and a “separate pathway”, so parents or carers are “prioritised for early discussion with a professional with relevant experience”.

On the suggestion of partial transition for young children and what this means, she suggested in some cases someone might be transitioned at home and not at school.

While focused on healthcare rather than issues in schools, Dr Cass acknowledged the area is “very difficult and very stressful for school staff, and for families”, adding: “So I do hope that the Government will find a way through that gives more reassurance to both.”

Prime Minister Rishi Sunak welcomed the review which he said “urges treating these children, who often have complex needs, with great care and compassion”.

He said: “We simply do not know the long-term impacts of medical treatment or social transitioning on them, and we should therefore exercise extreme caution.”

He said the Government had “acted swiftly” after the review’s interim report and “will continue to ensure we take the right steps to protect young people”.

NHS England said it was “very grateful to Dr Cass and her team for their comprehensive work on this important review”, and that it would “set out a full implementation plan following careful consideration of this final report and its recommendations”.

Health and Social Care Secretary Victoria Atkins said she was “grateful” to Dr Cass for her work on the review and pledged to work with NHS England to implement “further changes as soon as possible to ensure that the support given to children and young people is caring and careful”.

Labour’s shadow health and social care secretary Wes Streeting said the report “provides an evidence-led framework” to deliver the best care for children.

He called on the Government to “immediately act” and promised that if they do not, a Labour government “will work to implement the expert recommendations”.

Thanking the team for “the thoughtful and thorough way in which they’ve undertaken their work”, he added that it is “vital that our politics takes an equally thoughtful and thorough approach” and committed to working constructively with the Health Secretary “to put children’s health and wellbeing above the political fray”.