Cass Review – final report and

# recommendations

Cass.independent -review.uk Twitter: @TheCassReview

Scope & background

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## The aim of the Cass Review is to ensure that children

## and young people who are questioning their gender

## identity or experiencing gender dysphoria, and

## who need support from the NHS, receive a high

## standard of care that meets their needs and is safe,

## holistic and effective .

## This Review is not about defining what it means to be

## trans, nor is it about undermining the validity of trans

## identities, challenging the right of people to express

## themselves, or rolling back on people’s rights to

## healthcare. It is about what the healthcare approach

## should be, and how best to help the growing number

## of children and young people who are looking for

## support from the NHS in relation to their gender

## identity. Context

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• Gender care for children and young people originally based

on a counselling and therapeutic model

• Following introduction of Dutch protocol for early puberty

use, UK followed by trialling puberty blockers under a

research protocol from 2011 (‘the early intervention study’)

• In 2014 the service moved off protocol to routine prescribing

of puberty blockers

• Puberty blockers were given to a wider group of patients who

would not have been eligible in Dutch protocol

• Results of early intervention study published in 2020 – did

not show any improvement of psychological functioning or

gender dysphoria. Vast majority of those started on puberty

blockers went on to masculinising / feminising hormones.

• From 2014 – exponential increase in patients presenting to

gender services for children and young people. Reflected

internationally. Understanding the patient cohort (1)

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• The Review explored the reasons for the increase in referrals and why this increase has

disproportionately been of birth registered females presenting in adolescence, and the

implications of this for the service.

• This is a heterogenous group, with broad ranging presentations often including complex

needs that extend beyond gender related distress which needs to be reflected in the

services offered to them by the NHS.

• Common associated presentations include:

• Neurodiversity

• Higher rates of adverse childhood experience compared to general population

• High rates of trauma / family stressors

• Range of mental health issues including depression, anxiety Understanding the patient cohort (2)

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• Presentation of gender questioning young people needs to be understood

in context of other factors which are relevant for this population of children

and young people (largely Gen Z)

• Deterioration in mental health, particularly females in adolescence

• Impact of social media

• Potential online harms

• Changed generational perceptions about gender expression and

fluidity Understanding the patient cohort (3)

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# International position

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• The evidence base remains weak, and this is true of medical and non -medical interventions.

• International guideline development has not followed standard evidence -based approaches.

• The World Professional Association for Transgender Health has influenced most other international

guidelines.

• The only guidelines which have taken an independent and evidence -based approach are the

Swedish and Finnish guidelines.

• Based on the changed population being seen and the even weaker evidence base for this newer

group, they recommend a cautious approach to treatment. Approach to care

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• The central aim is to help young people to thrive and achieve their life goals. The immediate goal of

the treatment plan must be to address distress and any barriers to participation in everyday life

(e.g. school community or social activities), if it is a part of the child/young person’s presentation.

• The Review worked with a clinical expert group to develop a holistic assessment framework which

provides a starting point for services to assess immediate risk and determine the complex care

needs of the children and young people referred to the service.

• However, it is important to note that clinicians are unable to determine with any certainty which

children and young people will go on to have an enduring trans identity. Psychological interventions

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• The evidence base for use of psychological interventions in gender dysphoria

has all the same weakness as the evidence base underpinning medical

treatment.

• We know that many psychological therapies have a good evidence base for

treatment in the general population for conditions that are common in this group,

such as depression and anxiety. This is why it is so important to understand the

full range of needs and ensure that these young people have access to the same

helpful evidence -based interventions as others.

• The intent of psychosocial intervention is not to change the person’s perception

of who they are, but to work with them to explore their concerns and experiences

and help alleviate their distress regardless of whether or not a young person

subsequently proceeds on a medical pathway. Social transition

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• There is no evidence that social transition has either positive or negative effects on mental health in children

and weak evidence in adolescents.

• There is some suggestive evidence that social transition may change the trajectory of gender development in

young children

• The Multi -Professional Review Group, which has reviewed approximately 200 cases of children referred by

GIDS for endocrine treatment, has found that children approaching puberty ‘in stealth’ are in a state of anxiety

about being ‘outed’ which drives an urgency for puberty blockers.

Recommendation 4: 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. Medical interventions - Evidence

• The evidence base remains weak. Systematic reviews of puberty blocker use and of

masculinising/feminising hormones do not show clear benefit due to:

• The weakness of the research methodology

• The failure to document or take account of the changed population

• The inadequacy of follow up periods, and lack of long term data

• Conflation with other interventions

• Our attempt to fill some gaps in the evidence through a linkage study have been hampered by a

lack of cooperation from the adult gender clinics

• This limits the ability to obtain informed consent due to the difficulty of determining whether an

endocrine pathway is indicated in a particular individual and the limitations on evidence about risk /

benefit that can be given to the patient

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# Stability of gender identity

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Rawee , P., Rosmalen , J.

G. M., Kalverdijk , L., &

Burke, S. M. (2024).

Development of Gender

Non -Contentedness

During Adolescence and

Early Adulthood.

Archives of Sexual

Behavior .

s10508 -024 -02817 -5Interventions and Research

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Recommendation 6 : The evidence base underpinning medical and non -medical

interventions in this clinical area must be improved. Following our earlier

recommendation to establish a puberty blocker trial, which has been taken forward by

NHS England, we further recommend a full programme of research be established. This

should look at the characteristics, interventions and outcomes of every young person

presenting to the NHS gender services.

• The puberty blocker trial should be part of a programme of research which also

evaluates outcomes of psychosocial interventions and masculinising / feminising

hormones.

• Consent should routinely be sought for all children and young people for enrolment

in a research study with follow -up into adulthood.

Recommendation 8: NHS England should review the policy on masculinising / feminising

hormones. The option to provide masculinising/feminising hormones from age 16 is

available, but the Review would recommend extreme caution. There should be a clear

clinical rationale for providing hormones at this stage rather than waiting until an

individual reaches 18. Service model

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# Key service recommendation

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Recommendation 17 : A core national data set should be defined for both specialist and designated local

specialist services.

Recommendation 22 : Within each regional network, a separate pathway should be established for pre -

pubertal children and their families. Providers should ensure that pre -pubertal children and their

parents/carers are prioritised for early discussion with a professional with relevant experience.

Recommendation 23 : NHS England should ensure that each Regional Centre has a follow -through

service for 17 –25 -year -olds; either by extending the range of the regional children and young people’s

service or through linked services, to ensure continuity of care and support at a potentially vulnerable

stage in their journey. This will also allow clinical, and research follow up data to be collected.

Recommendation 28 : The NHS and the Department of Health and Social Care need to review the

process and circumstances of changing NHS numbers and find solutions to address the clinical and

research implications. Implementation and system learning

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Wider system learning

Recommendation 31 : Professional bodies must come together to provide leadership and guidance

on the clinical management of this population taking account of the findings of this report.

Recommendation 32 : Wider guidance applicable to all NHS services should be developed to

support providers and commissioners to ensure that innovation is encouraged but that there is

appropriate scrutiny and clinical governance to avoid incremental creep of practice in the absence

of evidence. Concluding thoughts

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While the Review has been focused on children and young people with gender incongruence and

gender related distress, the NHS needs to be ambitious for all children and young people seeking

NHS support.

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NHS provision for children and young people across the board requires service and workforce

development increased and sustained investment. We are letting down future generations. NHS

England should use this opportunity to integrate investment and development of gender services

with the ambitions set out in the NHS Long Term Plan for broader provision, with consideration

given to a complex adolescent pathway.

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Since the launch of the report, a large amount of misinformation / disinformation about the

approach and findings has been disseminated on social media. The Review has generated a series

of FAQs to address this, alongside the commentators who have been actively correcting

misinformation