The Cass review: What it is and what it means for trans youth

Today (Wednesday 10 March) the Cass review was published. It’s a major report looking into the provision of gender-affirming care for trans people in England.

Led by Dr. Hillary Cass, a former president of the Royal College of Paediatrics and Child Health, it was commissioned in 2020 to look into the provision of such services following a rise in the number of young people using them.

Wednesday’s nearly 400 page report makes 32 recommendations about gender identity services and assesses the available evidence to back up the current system. Already a lot has been made of the report, its findings, and recommendations so we have broken it down.

What was the aim of the Cass review?

In 2020, the Cass review set out to look into gender identity services for young people in England. It published an interim report in 2022 that found “gaps in the evidence” around the use of puberty blockers. These have been given to trans youth as a form of gender-affirming care. The interim review also suggested implementing a regional model for gender-affirming care rather than relying on the Gender Identity Development Service run by the Tavistock and Portman NHS Foundation Trust. Two new centers, one in London and another in Liverpool were hoped to open in April 2024 but are having issues recruiting staff.

Last month, NHS England announced it would stop prescribing puberty blockers to children. It said, “there is not enough evidence to support the safety or clinical effectiveness.” To clarify, this is a pause, not a ban.

What has the Cass review recommended?

In the final review, Dr Cass has made 32 recommendations about gender identity services. Among them are that “services must operate to the same standards as other services seeing children and young people.” She has also called for young people to get “a holistic assessment of their needs to inform an individualised care plan.” This would involve a mental health assessment as well as screening for neurodevelopmental conditions such as autism. The review also recommended moving away from a single national service towards a series of regional centres.

Dr Cass has also called for an improvement in the evidence underpinning any interventions for trans youth. The report also recommended that NHS England review its policy on prescribing masculinising/feminising hormones. It has advised “extreme caution” on prescribing them to 16-year-olds and said there should be “a clear clinical rationale” for providing hormones to under-18s.

You can check out the full review and all the recommendations here.

What else has Cass said in the review?

In her review, Dr Cass commented on the strength of the debate around trans healthcare recognising those supporting and against gender-affirming care. She criticised both sides as making “strong and widely divergent opinions unsupported by adequate evidence.” Off of that, she made multiple mentions of the “remarkably weak evidence” in the field. At one point she wrote: “The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.” She also said that evidence is unclear if socially transitioning has any positive or negative mental impacts.

She also addressed trans youth directly, saying she had been “very mindful” that her recommendations would be disappointing for many. But she defended herself and the review as making sure that “the best combination of treatments” is in place. She also, controversially, draws connections between neurodiversity and being trans. This has been criticised in the past by groups such as the trans charity Mermaids and continues to be by others.

What is going to be the impact in real terms for trans people?

Speaking to Attitude as the review was published Dr Aidan Kelly, a Consultant Clinical Psychologist and the founder of Gender Plus and the Gender Plus Hormone Clinic, the only independent Care Quality Commission registered gender identity clinic serving children and adults, said the review “isn’t going to fundamentally change very much” with many trans people considering non-NHS options.

He then expressed concern about how the review will be implemented and how realistic the expectations are. Pointing to the issues staffing the two new centres in Liverpool and London, Dr. Kelly said “It is going to be a long, slow process” which he added means people will give up on the NHS. Ultimately, though, he said “It’s not going to have a huge amount of impact until there’s a functioning service within which to put it into practice. There’s no harm in being careful and considered, but we need to be clear that that’s not just deliberately delaying something because we’re afraid to make a decision. Delaying something for the sake of delaying it is causing harm and that isn’t an evidence-based approach for anything.”

Connecting the review to pushes for a ban on ‘conversion therapy,’ Dr Kelly added: “We need to be very careful that these services don’t become ways our services that practice ‘conversion therapy’ in disguise.” He then urged people to be “neutral on whether someone identifies as trans or not” as well as to be respectful.

What has the response been?

The responses to the review have been varied. Some in gender-critical circles have celebrated the review as reinforcing their views and opinions. Meanwhile, many working with trans youth, in the medical sector, and beyond have criticised the review for a number of reasons.

Some have focused on the report’s omission of evidence including studies around puberty blockers that have not used control groups. People have argued that control groups in these studies would be impossible because people would know if they’d been given a placebo or a puberty blocker as they’d be experiencing puberty. Speaking on this Dr Kelly countered the claims of a lack of evidence citing his experience treating trans children and adults. Describing some of the requirements for evidence as being “overly stringent and unrealistic” he reasoned that “it’s quite logical to turn around and say there’s not enough evidence when you make it really hard to qualify what is ‘good enough’.”

Speaking further on this, Dr Kelly highlighted a recent German report, similar to the Cass review, which was very supportive of puberty blockers. “It just feels like it’s England diverging from the international consensus. It’s quite an insular position that’s been taken,” he added. Dr Kelly also expressed concern at the emphasis the review places on the minority of people who have gone on to de-transition. Recognising that people who decide to de-transition need support and care as well, Kelly suggested the emphasis showed Cass and NHS England had “caught fear” from the surrounding debate around trans.

Others have claimed the report has not spoken to trans people or trans-supportive groups/organisations. The review does state that it has heard “directly” from people with “lived experience.”

How has NHS England responded?

NHS England has welcomed the review and said it has made “significant progress towards establishing a fundamentally different gender service for children and young people.” This includes halting the use of puberty blockers as confirmed in March. “We will set out a full implementation plan following careful consideration of this final report and its recommendations,” NHS England added. “The NHS is also bringing forward its systemic review of adult gender services and has written to local NHS leaders to ask them to pause offering first appointments at adult gender clinics to young people below their 18th birthday.”

How have LGBTQ+ charities reacted?

Robbie de Santos, the Director of Campaigns and Human Rights at Stonewall has said the review can play “a vital role” in providing quality healthcare for trans children “if its recommendations are implemented properly.” He also said many “recommendations could make a positive impact” but that “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.” De Santos urged NHS England to “read and digest” the review and consider Dr Cass’ plea that everyone should be “treated with compassion and respect.”

The trans charity Mermaids said the review “echoes” much of what trans youth have been calling for – respect and support. “We are pleased the voices and experiences of trans young people appear to have been heard and respected,” the charity’s statement continued. However, the charity has expressed concern at the review’s use of language which it says is “open to misinterpretation and could be used to justify additional barriers to accessing care.” It also urged NHS England to “resist pressures” from those seeking to limit access to healthcare and to “listen to trans youth directly, and act urgently to provide gender services which are timely, supportive and holistic.”