Cass Review: gender services failing young people

NHS England says transformation of service will take time to fully deliver, but says it will work with the wider NHS and partners “to drive change as quickly as possible.”

Children and young people are being failed by gender identity services and there is "remarkably weak evidence" to support gender treatments for children, the Cass Review has concluded.

Dr Hilary Cass made 32 recommendations to ensure gender services operate to the same standards as other children's health services, so young people, their families, and those working with them can make informed decisions. The review details the recommended clinical approach to care, the support children and young people should expect, the interventions that should be available, and how services should be organised across the country.

NHS England, who commissioned the review in 2020 to look at gender identity services for under-18s, say a new evidence based clinical policy dictates that children will no longer routinely be prescribed puberty blockers outside of research trials, and has paused first appointments at adult clinics for teenagers under 18.

Dr Cass said: "The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress,” after a review of 53 studies on hormone treatments and 50 studies on puberty blockers found a lack of high-quality research into their use in young people.

Dr Roman Raczka, President-Elect of the British Psychological Society agreed, commenting: “it’s vital to create a sound evidence base and better understanding of the long-term effects of puberty blockers” to ensure young people make informed decisions about their treatment.

“It is extremely important that every child who is gender questioning has timely access to services that are holistic and respond to their individual needs.”

Recommendations also include a holistic assessment of needs, including screening for neurodevelopmental conditions including autism, and a mental health assessment. Dr Lade Smith CBE, President of the Royal College of Psychiatrists said children questioning their gender “commonly experience mental illness. It is extremely important that every child who is gender questioning has timely access to services that are holistic and respond to their individual needs.”

The review was commissioned in part to understand the reasons for a growth in referral to Gender Identity Development Service (GIDS). Dr Cass said there is “no denying there are increasing numbers of children and young people seeking support from the NHS for gender-related distress.” Such services are typically geared towards treating birth-registered males presenting in childhood, but there has been a rise among birth-registered females being referred in adolescents.

There is no simple explanation for the increases, but the review concludes “there is broad agreement that it is a result of a complex interplay between biological, psychological and social factors. This balance of factors will be different in each individual.”

Following recommendations in Cass’ interim report, the current GIDS centres will be replaced with eight new regional gender services centres, the first of which opened in April.

As a result of these increases, there are significant waiting times for services, leaving young people “underserved and vulnerable,” said Professor Steve Turner, President, Royal College of Paediatrics and Childrens Health (RCPCH). “It’s obvious that more resources are needed to address the holistic health needs of this young cohort. We are clear that the needs of children and young people should be front and centre of how services are designed to care for them.”

John Stewart, National Director, Specialised Commissioning, NHS England and Professor James Palmer, Medical Director, Specialised Commissioning, NHS England said, “The transformation and expansion of the service will take time to fully deliver, and the pace of progress will continue to be impacted by staffing challenges.”

They added, “NHS England will continue to work with the NHS and wider system partners to drive change as quickly as possible whilst also ensuring appropriate engagement and consultation.”