The independent review of gender identity services for children and young people1 chaired by leading paediatrician Dr Hilary Cass set out its final recommendations in April 2024. We review the key points and the recent change in the BMA’s stance on the report from critical to neutral.
What is the Cass Review?
Following concerns around the increase in referrals to the country’s only Gender Identity Development Service (GIDS), a working group was set up in January 2020 by NHS England to recommend how to improve gender identity services and ensure a high standard of safe, holistic care for under 18s. It would include a review of the evidence-base for transgender care and the GIDS service itself.
Dr Hilary Cass, a former President of the Royal College of Paediatrics and Child Health, was appointed to chair the policy working group given her expertise in child health and, specifically, because she had no involvement or fixed views in relation to this particular field.
Key questions were defined and, while nine studies met the criteria for review, these were, however, limited. ‘All the studies were small uncontrolled observational studies, and all the results were of low certainty. Many did not report statistical significance.’ (1 at 3.6).
The interim report was submitted to NHS England in February 2022 and the final report in April 2024.
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CQC involvement
One year on from the start of the review, the Care Quality Commission (CQC) published an inspection report of the Gender Identity and Development Service (GIDS),2 in response to whistleblowing concerns received. Commissioned by NHS England, it was based at the Tavistock and Portman NHS Trust.
The service was rated ‘Inadequate’ overall. Concerns were not limited to clinical practice, but included procedures relating to safeguarding, assessing capacity and gaining consent to treatment.
CQC found2 that, while patients were treated with dignity and kindness:
- The waiting list of 4600 was high and risks were not managed well whilst children and young people waited over two years for their first appointment
- Patients’ competency, capacity and consent had not been consistently recorded prior to January 2020
- Holistic care plans were not developed and records of clinical decision-making were not clear
- The specialists needed to meet individual patients’ needs were not always available
- The service was not consistently well led, with some identified improvements not made and some staff feeling fearful to raise concerns.
Key points from Cass
The report sets out the clinical approach to care and support children and young people should expect from gender identity services, including the interventions that should be available and how services should be organised across the country.
It also covers what needs to be in place to strengthen the evidence base underpinning care, covering quality improvement and research arrangements.
Key findings were:
- No explanation was identified for the growth in referrals
- Conflicting views were found about the clinical approach taken
- The research published in the field, though considerable, was unreliable and often misrepresented ‘both in scientific publications and social debate’1
- The rationale for the use of puberty blockers was unclear, with weak evidence about their impact
- The use of masculinising / feminising hormones in under 18s ‘presents many unknowns’1
- Innovation in medicine is important but must include appropriate monitoring, oversight and regulation.
Perhaps the most telling finding was:
‘For the majority of young people, a medical pathway may not be the best way to manage their gender-related distress. For those young people for whom a medical pathway is clinically indicated, it is not enough to provide this without also addressing wider mental health and/or psychosocially challenging problems.’1 Recommendations included:
- Providing more holistic healthcare to inform an individualised care plan, and not solely considering people in terms of their gender identity
- Operating services to the same standards as other children and young people’s services
- Establishing a separate pathway for pre-pubertal children so they can be seen early by a clinician with relevant experience
- Expanding service capacity, including a service for 17-25 year olds, to ensure continuity of care
- Providing for people considering detransition
- Establishing a full programme of research to cover every individual referred to the services
- Including the puberty blocker trial in the research programme
- Ensuring a clear clinical rationale for the use of masculinising / feminising hormones from age 16.
The review led to a new clinical commissioning policy preventing the prescribing of puberty blocking hormones to children and young people due to limited evidence around safety.7
BMA involvement
Concerns have been voiced about the Cass Review since its publication, most controversially from the British Medical Association (BMA), which became the only medical organisation in the UK to not accept Cass’s findings.3
In August 2024, the BMA Council passed a motion to ‘publicly critique the Cass Review’.4 It called, on 31 July 2024, for the Government’s ban on the use of puberty blockers to be lifted.
It also had concerns about:
- some of the methodologies used in the review
- difficulties arising from implementing some of the recommendations.
The decision was hugely unpopular with many BMA members, and led to around 1,500 doctors, including former heads of medical royal colleges, signing a letter of protest. Two months later, the BMA confirmed it had reverted to a neutral position while it completed its evaluation of the review. The lead for the evaluation, Professor David Strain, committed to undertake the work ‘from a position of neutrality’, moving ‘beyond polarising debates.’3
At the heart of the BMA’s stance was clear acknowledgement that current gender identity healthcare services are inadequate. It wants this rectified, with appropriate care and support made available, and ensuring that decisions are made, not by politicians, but based on evidence.
The BMA’s Task and Finish Group will present their report to the BMA’s UK Council in January 2025. It will include:
- a particular focus on the methodology underpinning the review’s recommendations
- principles and guidance for BMA policy work on transgender healthcare
- recommendations on ‘the need for additional or revised BMA policy, if necessary’.4
Action taken and next steps
Since publication of the final Cass Review in April 2024, NHS England has committed to implementing all recommendations proposed.5 A number of actions have already been taken:
- The Tavistock and Portman’s Gender Identity and Development Service (GIDS) closed in April 2024
- This has been replaced by the first two, in London and Liverpool in April 2024, of up to eight planned regional centres by 2026, based in NHS children’s hospitals.6 Bristol and the East of England will be the next to open, in November 20247 and Spring 20256
- They will operate to a fundamentally different model, with all referrals made via NHS secondary Paediatric or Mental Health Services, ensuring a holistic assessment of the children and young peoples’ needs.6,7 This also to ensure patients receive appropriate local support whilst on the waiting list.6
- A new interim service specification was published, taking a more cautious approach and led by psychosocial and psychological, rather than medical, professionals.7 This is expected to be updated by April 20256
- Further research has been agreed, to increase the evidence base and inform the best possible patient care, managed by a new NHS Research Oversight Board
- A clinical trial of puberty-blocking drugs is planned to start in early 2025
- A review into adult gender services is planned by NHS England with a view to agreeing an updated specification for the service7 and ensuring a seamless interface with the children and young people’s service.6
By Summer 2026, the final parts of NHS England’s plan will be in place,6 marking a significant shift in gender identity services since the September 2020 initiation of the Cass Review:
- All regional NHS transgender centres will be open
- A gender affirming hormone clinical policy will be in use
- A National Provider Collaborative will be in place to support a consistent approach
- An NHS pathway will be developed for children and young people who choose to detransition.7
Amanda Halliwell, Independent care coach
References
1. The Cass Review. Independent Review of Gender Identity Services for Children and Young People. cass.review@nhs.net (accessed 22 10 24) https://cass.independent-review.uk/
2. Care Quality Commission. Tavistock & Portman NHS Foundation Trust, Gender Identity Services, 20 January 2021. www.cqc.org.uk (accessed 22 10 24) https://www.cqc.org.uk/provider/RNK/inspection-summary#genderis
3. British Medical Association. Cass Review: Insight from the Front Line, 26 September 2024. www.bma.org.uk (accessed 22 10 24) https://www.bma.org.uk/news-and-opinion/cass-review-insight-from-the-front-line
4. British Medical Association. Press release from the BMA, 31 July 2024. www.bma.org.uk https://www.bma.org.uk/bma-media-centre/bma-to-undertake-an-evaluation-of-the-cass-review-on-gender-identity-services-for-children-and-young-people
5. NHS England. NHS England’s response to the final report of the independent review of gender identity services for children and young people, 10 April 2024, last updated 6 August 2024. www.england.nhs.uk (accessed 22 10 24)
6. NHS England. Children and young people’s gender services: implementing the Cass Review recommendations, 7 August 2024, last updated 29 August 2024. www.england.nhs.uk
7. NHS England. NHS to roll out six new specialist gender centres for children and young people, 7 August 2024. www.england.nhs.uk (accessed 22 10 24)