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.

The final report was published on 10 April 2024.

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.

The interim report also said that Cass considered 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

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 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

The report classified social transition as an "active intervention", and stated that children who socially transitioned were more likely to continue on to medical transition. The report advises caution in approaching social transition, and states that it should not be allowed without clinical involvement.

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 the majority of 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. The report 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, with the remaining studies being of moderate or 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.

Clinical pathways

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

The 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. The 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 holding off on allowing medical transition until a patient is in their mid-20s, advocating instead for providing "unhurried, holistic, therapeutic support" to patients under 25 - on the grounds that "clinicians are unable to determine with any certainty which children and young people will go on to have an enduring trans identity". The report further recommends that young adults seeking transition between the ages of 17-25 should be sent to a "follow-through service" rather than being allowed to access the adult clinic.

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, WPATH, ASIAPATH, EPATH, PATHA, and USPATH issued a statement criticizing the NHS England interim service specifications based on the interim report. It stated several points of contention with the report, including the pathologization of gender diversity, the making of "outdated" assumptions regarding the nature of transgender individuals, that it "ignores" newer evidence regarding such matters, and that it 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.

Final report

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 that the Cass report "provides an evidence-led framework to deliver that". In an interview with The Sun, Streeting stated that politicians have a "collective responsibility" to act in response to the Cass report. Speaking to Sky News, 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 Specialized 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 British Psychological Society commended the review as "thorough and sensitive", in light of the complex and controversial nature of the subject. Sallie Baxendale, professor of clinical neuropsychology at University College London, told The Guardian that the report "has laid bare the worrying lack of evidence to support the treatments that were prescribed by NHS clinicians to children with gender distress for over a decade."

The Professional Association for Transgender Health Aotearoa (PATHA), a New Zealand professional organisation, stated that the Cass Review made "harmful recommendations" and "ignores the consensus of major medical bodies around the world". The statement further said that "a number of people involved in the review and the advisory group 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".

Endocrinologist Ada Cheung, head of the University of Melbourne's transgender health research group, disputed the evidential findings regarding puberty blockers, saying that four studies rated as high quality already showed those treated with puberty blockers had less depression, less anxiety, less self-harm suicidality, and fewer problems interacting with peers.

Portia Predny, Vice President of the Australian Professional Association for Transgender Health, also disputed Cass’ conclusion that the evidence base for gender affirming care was weak, saying that the standard of evidence requested (randomized control trials) was neither feasible nor ethical to achieve.

Writing for The British Medical Journal, editor-in-chief Kamran Abbasi responded to criticism that the requested standard of evidence was infeasible, saying, "In fact, the reality is different: studies in gender medicine fall woefully short in terms of methodological rigour; the methodological bar for gender medicine studies was set too low".

The gender-critical movement has applauded the report. Genspect, JK Rowling, and Maya Forstater and her organization Sex Matters have spoken in support of the report. 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 criticized "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 raised concerns the review's recommendations may lead to barriers for transgender youth in accessing care.

External links

• Official website
• Systematic reviews

Further reading

• Taylor, Jo; Hall, Ruth; Langton, Trilby; Fraser, Lorna; Hewitt, Catherine Elizabeth (9 April 2024). "Care pathways of children and adolescents referred to specialist gender services: a systematic review". Archives of Disease in Childhood. doi:10.1136/archdischild-2023-326760. ISSN 0003-9888. PMID 38594052.