Hilary Cass: Insufficient Evidence Weakens Gender Care for Children
A landmark review has revealed that children have been let down by a lack of research and grossly insufficient evidence on medical interventions in gender care.
The Cass Review, which was published by paediatrician Dr Hilary Cass, calls for gender services for young people to match the standards of other NHS care.
She says the "toxicity" of the debate around gender meant professionals were "afraid" to openly discuss their views.
NHS England says it has already made significant progress in making changes.
The NHS England commissioned the Cass Review in 2020 in response to a surge in referrals of under-18s questioning their gender, following concerns raised by whistleblowers about care at the Gender Identity and Development Service (Gids).
Gids, the sole specialist gender clinic for young people in England and Wales, closed last week after being rated as "inadequate" four years prior. To address long waiting lists, now at approximately four years, regional hubs have been established in London and Liverpool, moving away from a single-service model.
The comprehensive 388-page Cass Review provides 32 recommendations on how gender services for young individuals should operate, covering aspects such as medical interventions, research, and safeguarding measures.
Dr Cass, therefore, calls for better research into the attributes of children seeking treatment and to review the outcomes for every young person.
She is clear that children and young adults using the services deserve the highest standards of care and research, which are expected elsewhere in the NHS.
Addressing children and young people in the foreword to her report, she wrote: "I have been disappointed by the lack of evidence on the long-term impact of taking hormones from an early age; research has let us all down, most importantly you."
"The reality is we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.
Dr Cass' report warns that this should only be done with "extreme caution" and there should be a "clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18".
The report also warns that younger children should be treated with a "more cautious approach" than adolescents when considering whether to allow them to change their names, pronouns or clothing - known as socially transitioning.
It says those who have not yet reached puberty should be "prioritised for early discussion with a professional with relevant experience" and they should be put on a separate care pathway than older, adolescent patients.
Dr Cass reiterated previous warnings that there was no clear evidence on whether social transitioning had positive or negative mental health outcomes.
She added that those who have done so at an earlier age, or before being seen by a clinic, were more likely to go down a medical pathway.
Dr Cass also warns parents should be mindful they are not "unconsciously influencing the child's gender expression".
She also recommends that young people aged 17-25 should have a "follow-through" service rather than going straight into adult services, as it recognised the age group as being at a "potentially vulnerable" stage of their journey.
About 15 years ago, gender identity services were seeing about 50 predominantly birth-registered boys in childhood, according to Dr Cass.
But over the last 10 years, that number has grown to more than 3,000 young people. "And it's mainly birth-registered girls presenting in early teens, and often with quite complex additional problems."
