Cass Review: professionals afraid to speak on trans kids issues

An independent review into gender identity services for children and young people in Britain has warned that healthcare professionals are afraid to discuss views on transgender services for children, and found there was no evidence puberty blockers or hormone drugs ‘buy time to think’ or ‘reduce suicide risk’ in that cohort. 

The report by paediatric consultant Dr Hilary Cass was undertaken as concern grew regarding the controversial provision of ‘gender-affirming care’ (where other mental health factors were not examined nor sufficient counselling given to children), and the huge spike in children presenting at clinics such as the now-closed Tavistock seeking to be put a treatment pathway to change sex.

Dr Cass has now made 32 recommendations, including an end to the prescribing of powerful hormone drugs to children and adolescents (under-18s), while also insisting that children who referred for gender services be screened for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment.

Outlining the research she had undertaken and the stakeholders she had spoken to, Dr Cass said that “despite the best intentions of everyone with a stake in this complex issue, the toxicity of the debate is exceptional”.

“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,” she wrote.

An interim report in 2022 from Dr Cass found the approach adopted by the Tavistock clinic – which provided services to children with gender dysphoria – was unsafe, that it overlooked other mental health problems in children, failed to collect data on the safety of puberty blockers, and did not subject the treatments administered to children to normal quality controls.

Dr Cass’s interim report also said that children being allowed to socially transition in schools was “not a neutral act”.

Based on the findings of the report, the British NHS announced in July 2022  that Tavistock – which facilitated sex-change therapies for children – would be closed down.

Some 238 young people in Ireland were sent to Tavistock since 2014 according to the HSE. 32 of those children were under 10 years of age, 2 were just five years old.

The key findings made by Dr Cass were: 

PUBERTY BLOCKERS

Dr Cass said that there was no evidence that puberty blockers “buy time to think” or “reduce suicide risk” – and that children who present as transgender should not be given any hormone drugs at all until at least 18. She warned that drugs that supressed puberty had no effect on the person’s body satisfaction or how they experienced gender dysphoria.

Urging ‘extreme caution’, the Review said that: “rhe option to provide masculinising/feminising hormones from age 16 is available, but the Review recommends extreme caution. There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18.  Every case considered for medical treatment should be discussed at a national Multi- Disciplinary Team (MDT).”

A systematic review undertaken by the University of York for the Cass Review found “multiple studies demonstrating that puberty blockers exert their intended effect in suppressing puberty, and also that bone density is compromised during puberty suppression.”

“However, no changes in gender dysphoria or body satisfaction were demonstrated. There was insufficient/inconsistent evidence about the effects of puberty suppression on psychological or psychosocial wellbeing, cognitive development, cardio-metabolic risk or fertility,” the report found.

She also warned of “concern that [puberty blockers] may change the trajectory of psychosexual and gender identity development”, and noted that most patients went on to take cross-sex hormones.

Her review found that the younger that children started gender identity treatment, the more likely they were to continue on to cross-sex hormones, leading to the Review’s conclusion that the drugs “are not buying time to think”.

She urged that all children and teenagers should be given time “to keep options open during this development window” – and that other conditions could also then be explored while preserving the patient’s fertility.

SOCIAL TRANSITIONING FOR YOUNG CHILDREN

The Review recommended that families of young children should be seen by a clinical professional before making decisions regarding social transitioning – changing names in school for example or using toilets of their choice.

“When families/carers are making decisions about social transition of pre-pubertal children, services should ensure that they can be seen as early as possible by a clinical professional with relevant experience,” the report says.

Dr Cass stresses the need to avoid “premature decisions” and seeking professional help early on to understand and assess the child’s behaviour and explore whether they are experiencing mental health issues or distress.

Research conducted for the review found that young children who socially transition were more likely to undergo medical treatment for gender change later.

She wrote: “There should be a distinction for the approach taken to pre- and post-pubertal children,” she said. “This is of particular importance in relation to social transition, which may not be thought of as an intervention or treatment because it is something that generally happens at home, online or in school and not within health services.”

And the report explained: “social transition in childhood may change the trajectory of gender identity development for children with early gender incongruence”.

The younger children are when they present with “gender incongruence” the more likely they are to move on from that phase, it says.

“The current evidence base suggests that children who present with gender incongruence at a young age are most likely to desist before puberty, although for a small number the incongruence will persist.”

TRAUMA PREVALENT AMONGST TRANS CHILDREN 

The Review found that a systematic review found as many as two thirds of those referred for gender identity treatment had suffered some kind of neglect or abuse, with high levels of parental mental illness, substance abuse and exposure to domestic violence.

The research found about half of cases referred to gender services had suffered from maternal mental illness or substance abuse while almost 40 per cent had experienced paternal mental illness or substance abuse – while a study of UK cases found one quarter of children had spent some time in care.

Some 40% had experience of family mental health problems.

“Children/young people referred to NHS gender services must receive a holistic assessment of their needs to inform an individualised care plan. This should include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment,” the report said.

It also looked at the growing number of adolescent girls now presenting with gender dysphoria.

“There is no simple explanation for the increase in the numbers of predominantly young people and young adults who have a trans or gender diverse identity, but there is broad agreement that it is a result of a complex interplay between biological, psychological and social factors. This balance of factors will be different in each individual,” the Review found.

REGRETTING TRANSITIONING
The report suggests that children need time to think before being rushed into a decision they may regret – and that too many decisions about changing gender were rushed.

A survey included in the findings found “the history of the child/young person’s gender journey was rarely examined closely for signs of difficulty, regret or wishes to alter any aspect of their gender trajectory.”

The review consulted with those who have transitioned to the opposite sex and those who have detransitioned (reversed a sex change). It found that “whilst some young people may feel an urgency to transition, young adults looking back at their younger selves would often advise slowing down”.

It continued: “For some, the best outcome will be transition, whereas others may resolve their distress in other ways. Some may transition and then de/retransition and/or experience regret. The NHS needs to care for all those seeking support.

Under-25s MUST ALSO NOT BE RUSHED

Under-25s should receive “unhurried, holistic, therapeutic support”, Dr Cass said, and not be rushed into changing gender. She said “life-changing” decisions required consideration in adulthood, and noted that brain maturation continues into the mid-20s.

The Review found that “clinicians are unable to determine with any certainty which children and young people will go on to have an enduring trans identity”.

“When making life-changing decisions, what is the correct balance between keeping options as flexible and open as possible as you move into adulthood, and responding to how you feel right now?” Dr Cass said.

The report noted: “It used to be thought that brain maturation finished in adolescence, but it is now understood that this remodelling continues into the mid-20s as different parts become more interconnected and specialised,” the report notes.

“Changes in the limbic area, which is ‘present-orientated’ and concerned with risk taking and sensation seeking, begin with puberty; this part of the brain becomes super sensitised, drives emotional volatility, pleasure and novelty seeking, and also makes adolescents more sensitive to social rejection, as well as vulnerable to addiction and a range of mental health problems.”

FEAR OF BEING LABELLED TRANSPHOBIC 

The Review heard concerns from many parents about their child being socially transitioned and affirmed in their expressed gender without parental involvement. This was predominantly where an adolescent had “come out” at school but expressed concern about how their parents might react.

“This set up an adversarial position between parent and child where some parents felt “forced” to affirm their child’s assumed identity or risk being painted as transphobic and/or unsupportive,” the Review found.