Gender care review: Children 'let down' by research amid 'exceptionally toxic' debate

A long-awaited report commissioned by NHS England has shone a new light onto the difficult and often emotive questions surrounding young people with gender identity issues, ITV News Social Affairs Correspondent Stacey Foster reports

Children seeking gender treatment have been "let down" by "remarkably weak evidence" supporting their care, according to a major review, which said the debate around the topic has become exceptionally toxic.

Healthcare professionals have been afraid to openly discuss their views in a conversation which has seen people bullied and vilified on social media, Dr Hilary Cass, a retired consultant paediatrician, said in her final report.

The long-awaited report of Dr Cass' independent review of gender identity services for children and young people runs to almost 400 pages and has been close to four years in the making.

The review was commissioned by NHS England in 2020 after a steep rise in the number of children and young people presenting to the NHS for help around their gender.

Over the last decade, as cases have risen exponentially, concerns have been raised around the introduction of earlier medical interventions despite a lack of evidence on their use and long-term impacts.

The final report comes less than a fortnight after the Gender Identity Development Service (Gids) at the Tavistock and Portman NHS Foundation Trust closed and two new regional hubs opened in London and the north of England in an effort to move away from a single-service model.

Recognising the “significant, often challenging public debate” on this sensitive issue, 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”.

What did the report recommend?

The report makes 32 recommendations, including:

• A call 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.

• A call for the NHS to review its policy on giving children masculinising or feminising hormones from the age of 16, urging “extreme caution”.

• The youngest children – those who have not yet reached puberty – should have a “separate pathway” so they and their parents or carers are “prioritised for early discussion with a professional with relevant experience”.

• A call for a “follow-through” service for 17 to 25-year-olds rather than this “vulnerable” group going straight into adult clinics “to ensure continuity of care and support at a potentially vulnerable stage in their journey”. The report said teenagers are “falling off a cliff edge” in their care when they reach 17, with Dr Cass recommending there “should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18”.

While NHS England last month confirmed puberty blockers would no longer be given to children outside research trials, 16-year-olds can still be given hormones in the form of testosterone or oestrogen.

The use of such hormones, the review said, should be part of a research programme alongside a previously reported puberty blocker trial which is expected to be in place by December.

Prime Minister Rishi Sunak said the Cass Review's final report has shone a spotlight on the need to "move with extreme caution in these areas".

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LGBTQ+ charity Stonewall said the review can play a "vital role" in ensuring "that trans and gender-diverse children get the quality healthcare they they need and deserve", if its recommendations are "implemented properly".

"Many recommendations could make a positive impact – such as expanding provision of healthcare by moving away from a single national service towards a series of regional centres, while recognising that there are many different treatment pathways that trans children and young people might take," it added.

"But without due care, training or further capacity in the system, others could lead to new barriers that prevent children and young people from accessing the care they need and deserve."

Mermaids, a transgender youth support charity, said the “current system is failing trans youth” and called for the NHS to “resist pressures from those who seek to limit access to healthcare” and instead “act urgently to provide gender services which are timely, supportive and holistic”.

The Children’s Society has called for the report to “mark a watershed moment” in fostering an environment “which places the wellbeing and safety of all children at its heart”, while the Royal College of Psychiatrists said all gender-questioning children must get “timely access to services that are holistic and respond to their individual needs”.

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”.

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 and/or clothing.

When families are making decisions about social transitioning, it is important “parents are not unconsciously influencing the child’s gender expression”, the review said.

While there was no clear evidence that social transition in childhood has any positive or negative mental health outcomes, “those who had socially transitioned at an earlier age and/or prior to being seen in clinic were more likely to proceed to a medical pathway”, the review said.

Addressing young people directly in her foreword, Dr Cass recognised that while some will be pleased with her report, others who want urgent access to hormones and puberty blockers may be upset and disappointed.

On the standards of care to date, 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.”

Describing the personal challenges she had faced in compiling the report, Dr Cass referred to the “toxicity of the debate” being “exceptional”, as she was criticised for engaging with both groups keen on gender affirmation and those wanting a more cautious approach.

Knowledge and expertise of experienced clinicians has at times been “dismissed and invalidated”, she said, while young people have been “caught in the middle of a stormy social discourse”.

She wrote: “There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.”

She warned that “polarisation and stifling of debate” not only does not help young people but will also hamper essential research in an area with “remarkably weak evidence”.

“The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress,” she said.

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”.

Labour’s shadow health and social care secretary Wes Streeting committed to working constructively with the health secretary on the report’s recommendations “to put children’s health and wellbeing above the political fray”.

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