The Cass Review: Interim Report Published

We welcome today’s interim report from The Cass Review and its recognition that the current service model “is not a safe or viable long-term option“. The report deserves a detailed and considered reading, here we aim only to point to some key findings.

The interim report is accompanied by two research reports which surveyed healthcare professionals (general & specialist), which can be downloaded together with the full report via the publications section of the Review website. Dr Cass herself has also authored an OpEd in the BMJ, launching the interim report and as a call for the medical community to support respectful open debate on this issue in order to improve understanding and outcomes.

A lack of normal quality controls at GIDS

The review finds many shortcomings in clinical decision-making & accountability, data collection, safeguarding & consent-taking for medical interventions. There is a lack of “normal quality controls that are typically applied when new or innovative treatments are introduced“.

This is devastating to the reputation of The Tavistock and Portman NHS Trust, especially as it comes a year after a critical CQC inspection of the Gender Identity Development Service (GIDS) led to far-reaching changes.

The review points to the novelty of medical interventions introduced without oversight and the slim evidence: “It is also important to note that any data that are available do not relate to the current predominant cohort of late-presenting birth-registered female teenagers.

Hard to believe, but the endocrinologists who are legally responsible for the prescription of hormones are not “active partners in the decision-making process leading up to referral for hormone treatment” nor routinely party to deliberations about referral to endocrinology.

The review points out (with surely a strong pinch of understatement) the importance of endocrinologists adhering to GMC guidance and “in carrying out their legal responsibility“.

Source: Cass Review Interim Report

The review points to future work to better understand the complex and changing social and cultural environment that shapes young people’s ideas about gender identity, online, in school and elsewhere.

Social Transition is an active intervention, not a neutral act

Social transition is referred to as “an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning…it is not a neutral act, & better information is needed about outcomes.

Clincians ‘afraid’ to follow professional standards due to pressure

The review highlights “the important role of schools & the challenges they face in responding appropriately to gender-questioning children and young people” as something to be explored and recognises the polarised and strongly contested debate around gender identity healthcare for young people. It found clinicians “afraid” to follow their “training and professional standards” “because of pressure to take a purely affirmative approach.

“Primary & secondary care staff have told us that they feel under pressure to adopt an unquestioning affirmative approach & that this is at odds with the standard process of clinical assessment & diagnosis that they have been trained to undertake in all other clinical encounters”

The review envisages no centralised GIDS but a regional service based in primary care and Tier 3 CAMHS, where clinicians can see the child’s problems in the round and formulate plans based on more rigorous and transparent assessments with a commitment to evidence and data-gathering.

Acknowledgement of the role of schools

With many Bayswater parents having school-aged children, it was heartening to see the Review acknowledge the possible role that schools play in the management of gender distress in our children and adolescents. Some key points from the review that parents may wish to highlight with their own schools:

  • Social transition is an active intervention, not a neutral act
  • A recognition that a child’s experience of gender and sexuality can be fluid right up until the mid-20s
  • There is a limit to how much certainty can be achieved in the late teens
  • Long term outcomes of social transition cannot yet be assessed
  • The majority of children and young people presenting to GIDS have other complex mental health issues and/or neurodiversity. There is also an over-representation of looked after children.

We have produced a quick guide to how this review has wide-ranging implications for schools, which can be downloaded here.

The interim report gives us hope that in future our children will receive care that is based on scientific evidence and data on outcomes, rather than ideological positions. As we digest the review’s work, we will have more to say. We encourage everyone to read it.

Further reading:

Review of gender identity services for children and young people written by Dr Hilary Cass and published in the BMJ, which we suggest you may wish to read alongside the full report.

‘Unsustainable’ Demand for NHS Gender Identity Service, Says Cass Review in Medscape