The final Cass Independent Review of Gender Identity Services for Children and Young People was released in April 2024. Commissioned by the National Health Services (NHS) in England in autumn 2020, so four years in the making, the review is comprehensive, clearly and painstakingly explanatory and already controversial.

 

The review repeatedly states it is based on commissioned peer-reviewed systematic reviews (published as eight journal articles in the Archives of Disease in Childhood, with a ninth being an online survey), on advice from clinical experts in relevant fields and through engaging stakeholders through multiple methods.

 

The eight systematic reviews regarding gender dysphoria in children and adolescents, executed through the University of York, cover the following: social transition, psychosocial support interventions, clinical guideline quality, clinical guideline recommendations, puberty suppression interventions in adolescents, masculinizing and feminizing hormone interventions for adolescents, characteristics of minors referred to specialist gender services and care pathways.

 

An included separate document contains overviews of key findings and recommendations, both in 11 bullet paragraphs, found at this link.

 

The review has 263 main pages, 387 pages with appendices, but the condensed summary and recommendations on pages 20-45 create the executive summary, and it is faithful to the hundreds of other pages of reports and studies. The summary includes 28 recommendations. Subsequent explanatory sections such as psychological and psychosocial interventions, social transition, medical pathways, puberty blockers and challenges in decision making each end with their own brief conclusion segments. The final portion on service model discusses the existing service model, the proposed new model, pathways and their implementation. The review ends with glossary, references and appendices.

 

Honest and for true, if you read only the 25-page summary and recommendations section (their executive summary), the overview of key findings and recommendations section (900 words of their bullet paragraphs, 11 items for each) and finally look through the nine study abstracts, you are more than fine.

 

Bullet points, My own

Though the previously mentioned overviews document for findings and recommendations (11 bullet paragraphs for each) comes in at a reasonable 900 or so words, my eye was caught by the following points in the review:

 

• Of all international guidelines, only those of Sweden in 2022 and Finland in 2020 could be recommended (para.44,45; p.28). They add (9.23, p.130), “They are the only guidelines that have been informed by an ethical review conducted as part of the guideline development.” Interestingly, the review notes these were the only two not influenced by WPATH SOC 7 and Endocrine Society 2009 (para.48; p.28). Regarding WPATH, “its guidelines were found by the University of York appraisal process to lack developmental rigour” (para.47, p.28). Furthermore, it notes WPATH SOC 8 then cited many other guidelines to justify some of its recommendations in a display of circular reasoning (9.21,p.130). “9.22 The circularity of this approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.”
• Identifying the “affirmative model” of “gender care” as American and crediting the U.S. with its spread throughout the “Western world” (glossary, p.235).
• Gender dysphoric minors have multiple unmet needs and require a holistic approach throughout with strong emphasis on mental health, even if they transition (para.13, p.21; recommendation 2,p.28; para.66, p.30).
• Systematic reviews of various elements of so-called gender-affirming healthcare (GAHC) consistently reveal poor/low quality.
• Social transition makes medical pathway more likely and demonstrates no clear evidence of positive or negative health outcomes in children, as well as weak evidence in adolescence (para.76, p.31).
• Repeated cautioning against rushed and premature decisions by patient and professionals (para 13, p.21).
• No evidence that social or medical transition/pathways reduce suicides (para.76, 86,15.43).
• No evidence that puberty-blocking agents buy time to think; most youth on them proceed to cross-sex hormones (para.83; p.32).
• Puberty-blocking agents compromise bone density, do not improve gender dysphoria or body satisfaction and “There was insufficient/inconsistent evidence about the effects of puberty suppression on psychological or psychosocial wellbeing, cognitive development, cardio-metabolic risk or fertility” (para.81, 82; p.32).
• Puberty-blocking agents will only be available in the context of a formal clinical trial of strong standards (para.84).
• Cross-sex hormones available from age 16 years of age and up, but with “extreme caution” under 18 (Rec.8; p.35). (Odd to recommend at all, when they say the evidence base is low/poor for such.)
• Cross-sex hormones “lack of high-quality research assessing outcomes.” “No conclusions can be drawn about the effect on gender dysphoria, body satisfaction, psychosocial health, cognitive development, or fertility” (para. 85, p.33).
• Medical pathway will only be available at tertiary care centers (para.111, p.36), requiring extensive mental health and psychosocial evaluation to qualify for a referral.
• All regional centers must have teams including a broad specialty mix—mental health, social work, pediatrics, neurodevelopmental, autism specialists and occupational health (para.116, p.37).
• Recognition of desistance and that children are most likely to desist, and therefore should be prioritized in the system because of that (para.144, Rec.22; p.41).
• Recognition of regret and detransition and that the NHS should care for all (para.13, p.21;Rec.25, p.43).
• Mandating the long-term and detailed collection of data, “a living systematic review,” to provide ongoing strong data and advisement (Para.91, p.33; para.135; p.41).

 

Poor Items (see also “No Bueno” section)

• Drawing lessons from differences [better recognized as “disorders”] of sexual development to apply to gender dysphoria, when these are two very different things (p.32, para.77).
• Belief that a medical pathway is best for a select few, when, in my opinion, there is always a more honest answer to gender dysphoria than chemical sterilization and surgical mutilation of healthy bodies (pp.21,27,30,37,40).
• Presupposing minors have competence to choose gender transition procedures. Intervention approach should “reduces distress and associated mental health issues and psychosocial stressors, so that the young person is able to function and make complex decisions” (p.30, para.63).
  • The Bell v. Tavistock decision of a United Kingdom high court noted, “There is no age appropriate way to explain to many of these children what losing their fertility or full sexual function may mean to them in later years.”
  • The chair of the Scottish Council on Human Bioethics wrote, “Children cannot consent, and therefore should not be asked to consent to being treated with puberty blockers for gender dysphoria.”
• Recommendation 10: “All children should be offered fertility counselling and preservation prior to going onto a medical pathway” (p.35). See the above quote from Bell v. Tavistock, “There is no age appropriate way to explain” this to many minors.
• Calling out the polarization, politization and emotionally charged nature of the issue (para.105, p.36), then repeating said error regarding “conversion therapy,” which I’m told is even a more hot button term in the UK than here in the U.S.
• Assuming bullying and minority stress are unique and major contributors, which is a manner of blame shifting (p.30, para.66).
  • A large nationally representative study out of Finland found transgender identity was “generally associated with perpetrating bullying” more so than “being bullied.”
  • Michael Bailey wrote that the minority stress was “prematurely accepted,” contradicts existing evidence and has other “serious limitations.”

 

I have a few other highlights to note. The systematic review of psychosocial interventions studies found their number (10) and quality low, but, “Most analyses of mental health and psychosocial outcomes showed either benefit or no change, with none indicating negative or adverse effects,” while the low number and low quality of the studies “limits conclusions.” The Cass Review further stipulated, “Despite this, we know that many psychological therapies have a good evidence base for the treatment in the general population of conditions that are common in this group, such as depression and anxiety” (Para.68, p.30). It then calls out diagnostic overshadowing, explaining, “…the focus on the use of puberty blockers for managing gender-related distress has overshadowed the possibility that other evidence-based treatments may be more effective” (Para.69, p.31). This leads to “Recommendation 3: Standard evidence based psychological and psychopharmacological treatment approaches should be used to support the management of the associated distress and cooccurring conditions. This should include support for parents/carers and siblings as appropriate.” This is in line with the strong pivot toward psychosocial and mental health focus for the gender dysphoric youth and family/caregivers noted in Sweden, Finland and Denmark, which is also being considered in other northern European nations.

 

The review often points out “the very limited evidence on the longer-term outcomes” (para.89, p.33) and “that research on psychosocial interventions and longer-term outcomes for those who do not access endocrine pathways is as weak as research on endocrine treatment” (Para.88, p.33). Poor medical record keeping was also pointed out in the Cass Interim Report. The review stated, “A strand of research commissioned by the Review was a quantitative data linkage study. The aim of this study was to fill some of the gaps in follow-up data for the approximately 9,000 young people who have been through GIDS” (Para.91, p.33). However, “despite efforts to encourage the participation of the NHS gender clinics, the necessary cooperation had not been forthcoming” (Para.92, p.33). This led to “Recommendation 5: NHS England, working with DHSC should direct the gender clinics to

participate in the data linkage study within the lifetime of the current statutory instrument.” With the NHS gender clinics thus far being a no-show for the data linkage study, a problem is at hand.

 

The review’s recommendations for the new service model and workforce (pp.36-38) struck me as painful to read. It details that the politically and emotionally charged arena already, “has impacted on the ability of the new services to recruit the appropriate multi-disciplinary workforce,” (para.104, p.36), and that, “The Review recognises that workforce shortfalls are one of the most challenging aspects of delivering this service” (Para. 112, p.37). So staffing is lean, but they are asking for far more staff. The following few paragraphs call for the establishment of a National Provider Collaborative with “considerable oversight duties” over regional centers to assure “shared standards and operating procedures, developing protocols for assessment and treatment” (Para.108). Furthermore, “each Regional Centre should work with local services within their region as a formalised Operational Delivery Network (ODN),” (Para.109), with medical intervention only “at tertiary level” (Para.111, p.36). When the UK is in a season of fiscal austerity, this is asking for a lot, but more is requested.

 

The review rightly desires staff with, “broad-based skills in adolescent physical and mental health so that young people are treated holistically and not solely on the basis of their gender presentation” (Para.114, p.37). The overwhelming probability of co-morbid mental health problems, adverse childhood events, challenging family dynamics and overrepresentation of autism spectrum disorder in minors with gender dysphoria merits no less. Then, paragraph 116 spells out the daunting list for staffing: “This workforce should include psychiatrists, paediatricians, psychologists, psychotherapists, clinical nurse specialists, social workers, specialists in autism and other neurodiverse presentations, speech and language therapists, occupational health specialists and, for the subgroup for whom medical treatment may be considered appropriate, endocrinologists and fertility specialists. Social care should also be embedded….” Paragraph 120 asks these professionals work “across related non-gender services within the tertiary centre and between tertiary and secondary centres,” and offers the reassurance this “has the additional benefits of not destabilizing existing services, supporting continuity and connection and democratising knowledge.” It sounds easily destabilizing to me by spreading staff too thin with too many duties in too many places.

 

The training and education section (p.38) wish for a “consortium of relevant Medical Royal Colleges and professional bodies” to “develop a shared skills and competency framework” (para.124,125) and training curricula. Recommendation 16 reads, “The National Provider Collaborative should coordinate development of evidence-based information and resources for young people, parents and carers.” Where were these organizations for what led to the closing of the world’s largest pediatric gender clinic, the NHS’s GIDS? Are they now trustworthy to generate, teach and test on evidence-based treatment of gender confused youth? Or do they require a bit of supervision? Part of the answer seems to follow.

 

The service improvement section (p.39) explains in paragraph 128, “there has been a failure to reliably collect even the most basic data and information in a consistent and comprehensive manner; data have often not been shared or have been unavailable.” This leads to Recommendation 17: “A core national data set should be defined for both specialist and designated local specialist services,” and Recommendation 18: “The national infrastructure should be put in place to manage data collection and audit and this should be used use this to drive continuous quality improvement and research in an active learning environment.” And the review has already informed us that, thus far, the NHS gender clinics are not cooperating.

 

The review section on transfer to adult gender services (p.42) explains that youth transfer from GIDS to adult services “represents a significant risk of discontinuity in clinical care and loss to follow-up. It also means that data on outcomes, which are essential to improve the knowledge base, are lost” (Para.146). The patients just fell off the radar. Thus, Recommendation 23 asserts, “NHS England should establish follow-through services for 17-25-year-olds at each of the Regional Centres,” to help plug the clinic and data how. What happens to the kids? They wish to know henceforth.

 

An interesting additional source of loss to follow up was addressed. Paragraph 161 (p.44) informs us, “Currently, when a person requests to change their gender on their NHS record, NHS guidance requires that they are issued with a new NHS number.” Just like that, the data is corrupted, with the patient’s natal sex and name replaced with a new trans-identified sex and new name. Recommendation 28 directs that, “The NHS and the Department of Health and Social Care needs to review the process and circumstances….”

 

May this modest review of the Cass Review final report serve you and your patients well.