What does Cass review mean for future of gender care?

Clinicians should use "extreme caution" when prescribing gender medical treatment to children, a new report has said.

The Cass review, led by consultant paediatrician Dr Hilary Cass, was commissioned in 2020 to assess international research into puberty blockers and to review gender services provided to children by the NHS. The key finding is that children have been let down by a "lack of research and evidence on medical interventions in a debate that has become exceptionally toxic", said The Guardian.

Warning that gender medicine is "built on shaky foundations", Cass said young people questioning their gender should be given a "holistic assessment", including a mental-health assessment and screening for neurodevelopment conditions such as autism, instead of being routinely prescribed puberty blockers.

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The newly published 388-page report made 32 recommendations overall. Interim findings published in February 2022 have already led to the closure of the "inadequate" Gender Identity and Development Service (Gids). And the NHS has altered its policies so that puberty blockers and cross-sex hormones can "only be given to gender-distressed children as part of clinical trials", said the BBC.

What did the commentators say?

Cass initially expected her review to be a "short, straightforward task", said Amelia Gentleman in The Guardian, but she found herself at the centre of a "vortex of a debate she describes as toxic, politicised and ideological". Cass's report is written in a "calmly clinical tone", but here "anger" over the level of treatment for children with gender identity issues is "barely disguised".

 Cass was aware her recommendations would be "hugely controversial", wrote Gentleman, and that some children awaiting treatment would be "dismayed by her conclusions", but insists that she has "young people's best interests at heart".

She clearly believes that while for a "minority of young people medical transition will be the right option", there is "no solid evidence basis justifying the use of hormones for children and adolescents".

The report's recommendations have not been universally welcomed. Its conclusions represented “an agenda from up on high that things need to be more difficult”, a mother of a 17-year-old trans girl told The Guardian. The report has already led to the closure of Gids at the Tavistock and Portman NHS Foundation Trust, leaving her child's care "up in the air".

Indeed, there are significant questions about how successfully the recommended level of care will be implemented. Regional care hubs, which opened this month, were described by sources as "nowhere near ready", said The Pink News. The director of the independent gender service, Gender Plus, Dr Aiden Kelly, told the site that he had "no doubt" that "much of what's been written in these reports won't be able to be fully implemented".

Others welcomed the implication of the report that treatment would begin to take a more evidence-based approach and that young people "will not be given life-altering drugs and surgery without proof that it will leave them happier and healthier than before", said Allison Pearson in The Telegraph.

It is clear that it continues to be an extremely "complex area of health", wrote Paul Gallagher at the i news site, but there is "hope that those children can look forward to much better care".

What next?

In response to the Cass review, NHS England said it would conduct a "systemic review of adult gender services" and lay out further plans for its services when children turn 18. 

The report also suggested that people using gender services should be asked to be part of research that will allow for greater, long-term understanding of patients' outcomes and evidence of treatment.

Prime Minister Rishi Sunak also suggested that an evidence-based approach to treatment was needed because "we simply do not know the long-term effects of these things". Shadow Health Secretary Wes Streeting said the report should be a "watershed moment" that leads to an "evidence-led framework" that is "free from culture wars".