Bayswater Statement in Response to the Final Report of the Cass Review

Bayswater Support Group statement on the final Cass Review report, April 2024

We welcome the findings of the final Cass Review Report, which represents a sea change in the treatment of trans-identified children and young people. Many Bayswater families feel both a sense of relief at the change of direction in NHS services, and sadness that this has taken so long and comes too late for some of our children. There is now a lot of work to do if we are to bring the NHS, schools, social care and charities in line with Dr Cass’ evidence-based approach aimed at protecting vulnerable children and young adults.

The report lays bare the “departure from normal clinical practice” at GIDs with the “adoption of a medical treatment with uncertain risks, based on an unpublished trial that did not demonstrate clear benefit”. The problems exposed go beyond the GIDS clinic itself and include a failure of clinical governance within the NHS. Cass notes that “whilst care cannot improve without innovation, good clinical governance should require collection of data and evidence with appropriate scrutiny to prevent the incremental creep of new practices without adequate oversight.” In contrast to the usual caution exhibited when rolling out innovative clinical interventions, “quite the reverse happened in the field of gender care for children.” There are important lessons to be learned here.

The field of gender medicine is characterised by “remarkably weak evidence”, yet a climate of fear has developed, and crucial debate and scrutiny has been stifled. Cass states that “there are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.” We agree.

Parents have routinely been excluded from significant decisions about their children, particularly over the issue of social transition, which the report confirms lacks a secure evidence base. Bayswater hopes that schools will heed the recommendation that “outcomes for children and adolescents are best if they are in a supportive relationship with their family. For this reason parents should be actively involved in decision making unless there are strong grounds to believe that this may put the child or young person at risk.” In an interview with The Guardian, Dr Cass also describes the way “online influencers” have been a source of “unbalanced information” and have fuelled parental alienation, with some young people “told that parents would not understand so that they had to actively separate from their parents or distance their parents.”

Considerable public debate has revolved around questions of individual autonomy and “informed consent”, but Cass is clear that a purely patient-driven model “is not an approach that would be compatible with GMC guidance with regard to the responsibilities of prescribers or for the safeguarding of minors”. Crucially, informed consent cannot be obtained without proper assessment of “whether a treatment is clinically indicated”.Looking to the future, we support the recommendation for a new service to extend up to age 25, offering young adults the same quality of care as younger patients. In the meantime, we are pleased to hear the announcement by NHSE that there will be a review of adult services and that first appointments at adult clinics should not be offered to 17-year olds. Bayswater is particularly concerned by the revelations in the Cass Report that the adult gender identity clinics refused to cooperate with tracking the outcomes of the roughly 9000 patients who were seen by GIDS. Cass has described this refusal as “coordinated” and “ideologically driven”. The Review encountered a similar lack of cooperation from the Tavistock and Portman Trust, which refused to share audit data on detransition collected by its adult clinic. NHSE must therefore take steps to ensure that its review of adult services is robust, transparent and independent to ensure there is proper scrutiny of the evidence base for the treatments on offer and the quality of patient care.

The focus on adult services is particularly urgent given the Cass findings that most of the patients at adult gender identity clinics (around 75%) come from the novel cohort with adolescent-onset gender issues that the Review identified as having disproportionate rates of psychiatric comorbidities, abuse and trauma. While it is important to recognise and reflect on the change in sex ratio in patients presenting to gender clinics (from predominantly male to predominantly female), it is also vital to note that many boys and young men exhibit the same vulnerabilities as the female patients and are equally deserving of evidence-led care.

Bayswater would also like NHSE to clarify what will happen to the many young people aged under 25 who are already on the adult waiting lists. Will those young people proceed into the adult clinics, with all the risks that have been identified? Or will they be eligible to be seen in the proposed 17-25 regional service? And it is not currently clear whether patients under 25 (or just under 18s) will be seen by the proposed Tier 2 psychological and psychosocial support service, to be commissioned by the regional services rather than NHSE.

Finally, we welcome the recommendation to provide support for detransitioners and the acknowledgement that they may not wish to engage with the service that facilitated their original transition. We also urge the Department of Health and Social Care and the General Pharmaceutical Council to act on the Review’s recommendation to consider statutory measures to prevent inappropriate overseas prescribing.

The report is highly detailed and we will continue to reflect on the implications of the findings. In the meantime, we would like to thank Dr Cass and her team for their work and for the contribution they have made to ensuring the best possible support for our children and young people.