Cass Review
The Independent Review of Gender Identity Services for Children and Young People is an independent review commissioned in 2020 by NHS England and NHS Improvement and led by Hilary Cass, a retired consultant paediatrician and the former president of the Royal College of Paediatrics and Child Health. It dealt with gender services for children and young people, including transgender youth and those with gender dysphoria in England.
The final report was published on 10 April 2024. The review made 32 recommendations across all aspects of service provision, which were largely welcomed by UK medical organisations, though some criticised parts of the review. The British Medical Association called to publicly critique the review and later initiated its own evaluation of it. The British Association of Gender Identity Specialist and UK's Association of LGBTQ+ Doctors and Dentists criticised the review. Medical organisations outside the UK, international medical organisations, and other countries' clinical practice guidelines have criticised its methodology, findings, and recommendations. Following high-profile media coverage, Cass expressed concern that misinformation about the review had spread online and elsewhere.
The review was endorsed by both the Conservative and Labour parties, although LGBT+ Labour criticised it. The Green Party initially supported the review, but pulled their statement following condemnation from LGBTQ members. LGBTQ advocacy groups in the UK and internationally have criticised the review.
The review concluded that the evidence base and rationale for early puberty suppression was unclear, which led to a UK ban on prescribing puberty blockers to those under 18 experiencing gender dysphoria. The Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust was closed in March 2024 and replaced in April with two new services, which are intended to be the first of eight regional centres. In August, the pathway by which patients are referred to gender clinics was revised and a review of adult services commissioned. In September, the Scottish government accepted the findings of a multidisciplinary team that NHS Scotland had set up to consider how the Cass Review's recommendations could best apply there. In England a delayed clinical trial into puberty blockers is planned for 2025.
Background
The number of referrals to GIDS, by sex assigned at birth, through different financial years.The Gender Identity Development Service was the specialist clinic nationally commissioned by NHS England to provide care to transgender and gender diverse children, including those with gender dysphoria. In the years leading up to the Cass Review, several GIDS staff members voiced concerns over the evidence base for the treatments being given and the extent of prior assessment. At the same time, professional disagreements over the strength of evidence for treatments provided to children and young people, such as puberty blockers, was growing. The case of Bell v Tavistock also explored issues of informed consent. Several systematic reviews had found the evidence base supporting these treatments to be poor, and European countries such as Finland and Sweden had limited the use of puberty blockers and other hormone treatments for this patient cohort, citing a lack of evidence supporting their use. In January 2021, the Care Quality Commission gave GIDS an "inadequate" rating. These issues led to GIDS becoming controversial and gaining extensive news coverage.
The median waiting time for GIDS patients' first appointments, by sex assigned at birth, through different financial years.
The Cass Review was commissioned by NHS England in September 2020, following a significant increase in referrals to GIDS and a shift in the service from a psychosocial and psychotherapeutic model to one that included hormone treatment. Hilary Cass, a former president of the Royal College of Paediatrics and Child Health, was asked by NHS England and NHS Improvement's Quality and Innovation Committee to chair an independent review with the aim of improving gender identity services for children and young people. The Cass Review's final report stated the concerns which led to its creation included very long waiting lists, of over two years per patient; an "exponential" increase in the number of children and young people requesting gender-affirming care from the NHS; a change towards earlier medical treatment in this patient cohort; and concerns that there was insufficient evidence to justify the treatments being given.
Methodology
The Cass Review was an independent review which made policy recommendations for services offered to children and young people questioning their gender identity or experiencing gender incongruence in the NHS in England. Dr Hilary Cass chaired the review and authored its recommendations and reports, independently of any medical bodies or consensus-building process. An assurance group was appointed, but was not involved in the preparation of recommendations. No external review or prior consultation was performed before publishing. An advisory board was also established, but the composition and contributions of the group are not documented.The Cass Review commissioned several independent systematic reviews from the University of York's Centre for Reviews and Dissemination, which were published in Archives of Disease in Childhood. Whether the research questions were decided by CRD researchers or the Cass Review is unclear.
The systematic reviews covered:
- Characteristics of children and adolescents referred to specialist gender services
- Impact of social transition in relation to gender for children and adolescents
- Psychosocial support interventions for children and adolescents experiencing gender dysphoria or incongruence
- Interventions to suppress puberty in adolescents experiencing gender dysphoria or incongruence
- Masculinising and feminising hormone interventions for adolescents experiencing gender dysphoria or incongruence
- Care pathways of children and adolescents referred to specialist gender services
- Clinical guidelines for children and adolescents experiencing gender dysphoria or incongruence
Interim report
The interim report of the Cass Review was published without peer-review in March 2022. It said the rise in referrals had led to staff being overwhelmed, and recommended the creation of a network of regional hubs to provide care and support to young people. The report said the clinical approach used by the Gender Identity Development Service "has not been subjected to some of the usual control measures" typically applied with new treatments, and raised concerns about the lack of data collection by GIDS. While most children referred to GIDS did not receive endocrine treatment, there was insufficient detail provided about their broader needs when they did.The report said that while the GIDS approach to hormone interventions was initially based on the Dutch protocol, there were "significant differences" in the current NHS approach. For example, the report said there were no clear guidelines for when to provide psychological support before or instead of medical treatment, endocrinologists administering puberty blockers did not attend multidisciplinary meetings, and there was insufficient capacity to increase appointments once adolescents received puberty blockers.
The interim report said GPs and other non-GIDS staff felt "under pressure to adopt an unquestioning affirmative approach" to children unsure of their gender. The report also said that diagnosis of gender-related distress sometimes led to "diagnostic overshadowing", where comorbidities such as poor mental health – which were usually managed by local services – were overlooked. The report suggested that long wait times to access GIDS had resulted in increased distress for patients and their families, as well as less time for exploration – since patients arrived having already begun social transition and with expectations of a rapid assessment process. In response, the Tavistock and Portman NHS Foundation Trust said "being respectful of someone's identity does not preclude exploration", and that it agreed "support should be holistic, based on the best available evidence" without making assumptions about "the right outcome for any given young person".
The interim report further said there were "gaps in the evidence" over the use of puberty blockers. A public consultation was held and a further review of evidence by NICE said there was "not enough evidence to support the safety or clinical effectiveness of puberty suppressing hormones to make the treatment routinely available at this time". Subsequently, NHS England stopped prescribing them to children.
In April 2022, Health Secretary Sajid Javid told MPs that services in this area were too affirmative and narrow, and "bordering on ideological". In November 2022, the World Professional Association for Transgender Health – along with regional groups ASIAPATH, EPATH, PATHA, and USPATH – issued a statement criticising the NHS England interim service specifications based on the interim report, stating it was based on outdated assumptions about transgender children and adolescents, that it relied on outdated or questionable studies on rates of persistence, and challenging the endorsement of psychotherapeutic gatekeeping on the grounds that "the denial of gender-affirming treatment under the guise of 'exploratory therapy'" was "tantamount to 'conversion' or 'reparative' therapy".