Cass Review

Logo of the Cass Review

The Independent Review of Gender Identity Services for Children and Young People (commonly, the Cass Review) was commissioned in 2020 by NHS England and NHS Improvement and led by Hilary Cass, a retired consultant paediatrician and former President of the Royal College of Paediatrics and Child Health. It dealt with gender services for children and young people, including those with gender dysphoria and those identifying as transgender.

The final report was published on 10 April 2024, and its recommendations were endorsed by NHS England and both the Conservative and Labour parties. The review has received criticism from some international medical organisations.

Background

The interim report of the Cass Review was published in March 2022. It said that the rise in referrals had led to the staff being overwhelmed, and recommended the creation of a network of regional hubs to provide care and support to young people. The report noted that the clinical approach used by the Gender Identity Development Service (GIDS) "has not been subjected to some of the usual control measures" typically applied with new treatments, and raised concerns about the lack of data collection by GIDS. While GIDS initially followed the Dutch protocol, the interim review said there were "significant differences" in the current NHS approach.^:18 Children with comorbidities did not receive adequate psychological support, endocrinologists administering puberty blockers did not attend multidisciplinary meetings nor did the frequency of meetings increase when adolescents received puberty blockers, all of which the Dutch Approach recommends.

The interim report further stated that GPs and other non-GIDS staff felt "under pressure to adopt an unquestioning affirmative approach" to children unsure of their gender, "overshadowing" other issues such as poor mental health. The Tavistock and Portman NHS Foundation Trust said "being respectful of someone's identity does not preclude exploration", and "We agree that support should be holistic, based on the best available evidence and that no assumptions should be made about the right outcome for any given young person."

The final report of the Cass Review was published on 10 April 2024. It included several systematic reviews of scientific literature carried out by University of York, encompassing the patient cohort, service pathways, international guidelines, social transitioning, puberty blockers and hormone treatments.

Findings

Lack of research

The report said that there is little high-quality research supporting current clinical guidelines and practice in trans healthcare in the NHS.

Increase in referrals

Cass Review Figure 11: Child and Adolescent Referrals for Gender Dysphoria (UK, GIDS)

The report found no clear explanation for the rise in the number of children and adolescents with gender dysphoria, but stated there was broad agreement for attribution to a mix of biological and psychosocial factors. Suggested influences included a lower threshold for medical treatment, social media-related mental health consequences, abuse, access to information regarding gender dysphoria, struggles with emerging sexual orientation, and early exposure to online pornography. The report considered a rise in acceptance of transgender identities to be insufficient to explain the increase.

Social transition

Main article: Social transitioning

A systematic review evaluated 11 studies assessing the outcomes of social transition in minors using a modified version of the Newcastle-Ottawa scale and considered 9 to be low quality and two to be moderate quality. The report stated that insufficient evidence was available to assess whether social transition in childhood has positive or negative effects on mental health, and that there was weak evidence for efficacy in adolescence. It also stated that sex of rearing seems to influence gender identity, and hypothesised that early social transition may change the way a child's gender identity develops.

The report classified social transition as an "active intervention". It also advised caution in approaching social transition, and stressed the need for clinical involvement in determining risks and benefits, saying that it is not a role that can be undertaken without appropriate clinical training.

Puberty blockers

Main article: Puberty blocker

The report stated that the evidence base and rationale for early puberty suppression remains unclear, with unknown effects on cognitive and psychosexual development. A systematic review examined 50 studies on the use of puberty blockers using a modified version of the Newcastle–Ottawa scale and considered only one to be of high quality, along with a further 25 being of moderate quality, and the remaining 24 being of low quality. The review concluded that the lack of evidence means no conclusions can be made regarding the impact on gender dysphoria and mental health, but did find evidence of bone health being compromised during treatment. The review disagreed with the idea of puberty blockers providing youth patients with "time to think", due to the finding that nearly all patients who went on blockers later decided to proceed on to hormone therapy. For transgender women, the report advised balancing the need to mitigate the effects of male puberty with the need to allow for a certain level of penile development in the event that the patient later wishes to pursue a vaginoplasty.

Hormone therapy

Main article: Transgender hormone therapy

The report stated that many unknowns remained for the use of hormone treatment among under-18s, despite longstanding use among transgender adults, with poor long-term follow-up data and outcome information on those starting younger. A systematic review evaluated 53 studies on transgender hormone therapy using a modified version of the Newcastle-Ottawa scale, and considered only one study to be of high quality, 33 moderate and 19 low quality. Overall, the review found some evidence that hormone treatment improves psychological outcomes after 12 months, but found insufficient/inconsistent evidence regarding physical risks and benefits. The review advised that there should be a 'clear clinical rationale' for the prescription of hormones under 18 years of age.

Psychosocial intervention

A systematic review assessed ten studies on the efficacy of psychosocial support interventions in transgender minors using the Mixed Methods Appraisal Tool and considered only one to be of medium quality, with the remaining nine being of low quality. The review concluded that no robust conclusions can be made and more research is needed. The report said that the evidence for "psychosocial intervention" as opposed to hormonal was "as weak as research on endocrine treatment", but that the result of psychological treatment was "either benefit or no change".

Clinical pathways

Cass Review Figure 34: Outline of medical pathway at start of Review

The report stated that clinicians cannot be certain which children and young people will have an enduring trans identity in adulthood, and that for most, a medical pathway will not be the most appropriate. When a medical pathway is clinically indicated, wider mental health or psychosocial issues should also be addressed. Due to a lack of follow-up, the number of individuals who detransitioned after hormone treatment was unknown.

The Cass Review attempted to work with the Gender Identity Development Service and the NHS adult gender services to "fill some of the gaps in follow-up data for the approximately 9,000 young people who have been through GIDS to develop a stronger evidence base." However, despite encouragement from NHS England, "the necessary cooperation was not forthcoming."

International guidelines

Cass Review Table 6: Critical appraisal domain scores

A systematic review assessed 23 regional, national and international guidelines covering key areas of practice, such as care principles, assessment methods and medical interventions. Most guidelines were stated to lack editorial independence and developmental rigour, and were nearly all influenced by the 2009 Endocrine Society guideline and the 2012 WPATH guideline, which were themselves closely linked. The Cass review questioned the guidelines' reliability, and concluded that no single international guideline regarding transgender care could be applied in its entirety to NHS England.

Conflicting clinical views

The report identified conflicting views among clinicians regarding appropriate treatment, with expectations of care sometimes deviating from clinical norms. It noted that disputes over language such as "exploratory" and "affirmative" approaches meant it was difficult to establish neutral terminology. Some clinicians feared working with gender-questioning young people. The report stated that some professionals were concerned about being accused of conversion practices, and were likewise concerned about legislation to ban conversion therapy. The report went on to say that many professionals were "overshadowed by an unhelpfully polarised debate around conversion practices".

Recommendations

The report made 32 recommendations covering areas including assessment of children and young people, diagnosis, psychological interventions, social transition, improving the evidence base underpinning medical and non-medical interventions, puberty blockers and hormone treatments, service improvements, education and training, clinical pathways, detransition and private provision.

The report recommended the development of a regional network of centres, and continuity of care for 17-25-year-olds.

On 11 April 2024, the Care Quality Commission announced it will check that licensed healthcare providers that are registered with the CQC which provide care to those who are questioning their gender identity are applying new guidance recommended by the Cass Review and will take enforcement action against private clinics that prescribe puberty blockers to under-18s in defiance of the NHS England's ban. However, while the CQC will expect all private providers registered with them to take the Cass recommendations into account, they do not have to comply with them as private providers are not bound by Cass's recommendations. However, at present no CQC-registered private gender care clinic issues puberty blockers.

Reception

Interim report

Some criticisms of the operation of GIDS that the Association of Clinical Psychologists UK (ACP-UK) drew from the Cass interim report were: GIDS took an approach that was predominantly affirmative, rather than exploratory; assessment was not standardised; mental health and neurodevelopmental assessments were not conducted comprehensively, leading to 'diagnostic overshadowing' whereby gender dysphoria was attended to without taking into account any co-existing diagnoses; safeguarding processes were lacking. In response, an open letter signed by more than forty clinical psychologists described the statement by the ACP as 'misleading' and said that it 'perpetuates damaging discourses about the work and gender-diverse identities more broadly'. Roughly half of the signatories were current or former senior employees at GIDS.

In November 2022, the World Professional Association for Transgender Health (WPATH), along with ASIAPATH, EPATH, PATHA, and USPATH issued a statement criticising the NHS England interim service specifications based on the interim report. It stated several points of contention with the report, including the pathologizing of gender diversity, the making of "outdated" assumptions regarding the nature of transgender individuals, "ignoring" of newer evidence regarding such matters, and making calls for an "unconscionable degree of medical and state intrusion" into everyday matters such as pronouns and clothing choice, as well as into access to gender-affirming care. It further noted that "the denial of gender-affirming treatment under the guise of 'exploratory therapy' is tantamount to 'conversion' or 'reparative' therapy under another name".

Final report

Prime Minister Rishi Sunak said that the findings "shine a spotlight" on the need for a cautious approach to child and adolescent gender care. Wes Streeting, the shadow Health Secretary, welcomed the final report, saying that the report "must provide a watershed moment for the NHS's gender identity services" and committing the Labour Party to implementing the report's recommendations in full. Speaking to Sky News, Shadow Home Secretary Yvette Cooper stated that Labour welcomed the Cass Review and committed to implementing all of its recommendations.

In response to the report, the NHS England National Director of Specialised Commissioning John Stewart sent a letter to Cass stating that it would review the use of gender affirming hormone therapy in adults in a similar manner as was done for puberty blockers in the Cass Review.

The Scottish Government said it would "take the time to consider the findings". SNP politician Joanna Cherry called for an overhaul to services in Scotland for gender-questioning children, including screening out neurodivergent patients, and an end to the use of puberty blockers. In contrast, Humza Yousaf, First Minister of Scotland and SNP leader, stated that the Cass Review did not validate closing the Sandyford gender identity clinic. On 18 April 2024, NHS Scotland announced that it had paused prescribing puberty blockers to children referred by its specialist gender clinic.

The World Professional Association for Transgender Health released an email statement that the report "is rooted in the false premise that non-medical alternatives to care will result in less adolescent distress" and further criticised recommendations which "severely restrict access to physical healthcare, and focus almost exclusively on mental healthcare for a population which the [World Health Organization] does not regard as inherently mentally ill".

The Professional Association for Transgender Health Aotearoa (PATHA), a New Zealand professional organisation, stated that the Cass Review made "harmful recommendations" and was not in line with international consensus, and that "Restricting access to social transition is restricting gender expression, a natural part of human diversity." They further stated that several people involved in the review "previously advocated for bans on gender affirming care in the United States, and have promoted non-affirming 'gender exploratory therapy', which is considered a conversion practice." A joint statement by Equality Australia signed by the Australian Professional Association for Trans Health (AusPATH) and PATHA among others stated the review "downplays the risk of denying treatment to young people with gender dysphoria and limits their options by placing restrictions on their access to care".

The Canadian Pediatric Society responded to the report by saying "Current evidence shows puberty blockers to be safe when used appropriately, and they remain an option to be considered within a wider view of the patient's mental and psychosocial health."

The Amsterdam University Medical Center put out a statement saying that while it agrees with the goals of reducing wait times and improving research, it disagrees that the research-base for puberty blockers is insufficient; asserting that puberty blockers have been used in trans care for decades.

The British Psychological Society commended the review as "thorough and sensitive", in light of the complex and controversial nature of the subject. The Equality and Human Rights Commission described it as a "vital milestone" and called for all service providers to fully implement the recommendations of the review.

The report was praised by some academics in the UK, who agreed with its findings stating a lack of evidence; while others both in the UK and internationally disagreed with the report's methodology and findings.

Gender-critical organisations including Sex Matters and Genspect welcomed the report, as did author JK Rowling. Stella O'Malley of Genspect cited the review as reason not to institute a ban on conversion therapy, saying that it "would ban the very therapy that Cass is saying should be prioritised".

Amnesty International criticised "sensationalised coverage" of the review, stating "This review is being weaponised by people who revel in spreading disinformation and myths about healthcare for trans young people." Trans youth charity Mermaids and the LGBTQIA+ charity Stonewall endorsed some of the report's recommendations, such as expanding service provisions with the new regional hubs, but raised concerns the review's recommendations may lead to barriers for transgender youth in accessing care.

Cass Response

In the week after the release of the final report, Cass described receiving abusive emails, and had been given security advice to avoid public transport. She also said that "disinformation" had been spread online about the report, to the point of being repeated in parliament. Cass stated "if you deliberately try to undermine a report that has looked at the evidence of children’s healthcare, then that’s unforgivable. You are putting children at risk by doing that." She characterized statements by critics, of the report dismissing 98% of studies reviewed as "completely incorrect", saying that although only 2% of the papers collected were considered to be of high quality, 60% of the papers, including those considered to be of moderate quality, were considered in the report's evidence synthesis. She criticized Dawn Butler MP for making such a statement to parliament. After talking with Cass, Butler subsequently used a point of order to admit their mistake in parliament, and correct the record.

External links

• Official website