An impartial review into the healthcare system for trans children in England, the Cass statement, has urged clinicians to utilize “extreme prudence” when prescribing puberty blockers to trans youth.
A comprehensive 400-page document into England’s type of care for trans under-18s published on Wednesday (10 April) claimed that there is “weak evidence” suggesting that puberty-blocking hormones positively or negatively impact gender dysphoria, while deeming traditional studies into its effects to be of “poor quality”.
The term “puberty-blocking hormones” refers to medication that stops unnecessary puberty-related changes. In the past, NHS England has labeled them as actually reversible.
In 2020, NHS England commissioned an independent assessment led by Dr. Hilary Cass to handle the increase in recommendations to the nation’s only youth gender clinic.
The suggestions made in the interim statement released in March 2022, which called for a decentralized approach to providing care in England in the form of local hubs, are expanded in this report.
It found that there is “no simple explanation” for the increase in young people who identify as transgender, non-binary, or gender nonconforming and that there are “conflicting views” on how to provide care for trans youth.
Cass added that there has been “considerable amount of analysis” done on the subject of scientific decision-making for youth gender services, but that the research has been criticized for being “poor quality” and uncertain.
The World Professional Association of Transgender Healthcare (WPATH), a recognized international authority for transgender medical assistance, is one such organization that it points to because it lacks “developmental rigor.”
Additionally, the report discovered that England did not adhere to international scientific guidelines in its entirety.
Cass stated in a statement that “what I’m recommending is a spread of power across the nation that is supported by pediatric service and delivered in a constant manner.”
She continued,” A much more systematic present of treatment that looks at the baby as a whole people and not just through the lens of their gender identity. And the creation of a strong research setting to give evidence on the long-term effects and efficacy of various interventions, so that potential care is informed by solid evidence.
Cass report advises people and pre-pubertal children to follow “individual channels”
The Cass report also advises that young people who are referred to a junior female doctor be assessed to “tell an individualized treatment program “including screenings for” developmental conditions like autism, depression, anxiety, and others. Decentralizing the model of care to regional hubs across England.
Services are also advised to establish separate pathways for pre-pubertal children and their families and give them priority among referrals.
Other options include a “follow-through” service for 17- to 25-year-olds that would transition patients to adult gender clinics.
The report advised clinical providers to exercise “extreme caution,” “adding that there should be a” clear clinical rationale” for providing puberty-blockers to under-18s, even though patients aged 16 and up will remain only available for clinic trials by NHS England.
Puberty blockers have been outlawed from clinical trials for a while, with additional steps being taken to stop prescriptions in March 2024.
“I have had to make recommendations based on the currently available information,” Cass wrote. “I am aware that this is a specific time period, and that new insights may emerge as new evidence is collected.
There is no conclusive evidence that” social transition has any positive or negative mental health outcomes,” despite research suggesting that “hormone treatment” lowers” the elevated risk of suicide.
However, those who had socially transitioned earlier and/or before going to the clinic were more likely to choose a career path.
I have no doubt that much of what these reports contain won’t be put to the test
Despite agreeing with a number of the recommendations made in the Cass report, clinical psychologist and director of the independent gender service, Gender Plus, Dr. Aiden Kelly, said that he disagrees with the report’s emphasis on the needs of detransitioners.
It’s not inconclusive to say that those needs are important; of course, we don’t want to make anyone’s life harder or more difficult than it needs to be, but it makes no sense for me to concentrate on the needs of the very small few at the expense of the vast majority.
Kelly claimed that the model of care is generally pointing in the right direction, even though the findings of the report were not wholly unexpected.
Being a professional in this field for a while, I’ve always been aware of that kind of comprehensive, holistic service that can meet their needs, not just in terms of gender but also in terms of other aspects of the needs of young people.
“That was the case in 2020 and remains the case. The bit that’s different now versus 2020, sadly, is that] we’re in a far worse position than we were when the review was commissioned”.
What Kelly is most fearful of, however, is the level to which the review’s recommendations will be fully implemented, saying that it’s “hard to remain hopeful” of significant change.
New regional hubs that began providing initial care in April were earlier this month described as “nowhere near ready.”
“I’ve no doubt that much of what’s been written in these reports won’t be able to be fully implemented”, Kelly said. These early regional hubs already showed these. They don’t know how to fill these positions.
It’s been a bit of an illustration of perhaps how not to provide a pathway. They’ve shut down] The Tavistock Service] without being able to know how to fully resource the new replacement services.”
Stonewall’s director of campaigns and human rights, Robbie de Santos, shared similar qualms in a statement to PinkNews, saying that” what is important, above all, is that trans and gender-diverse children get the quality healthcare they need and deserve.”
Many suggestions could have a positive impact, such as expanding healthcare by moving away from a single national service to a number of regional centers, while acknowledging that trans young people may have many different treatment options.
Who is Dr. Hilary Cass?
Dr. Hilary Dawn Cass, a former consultant in pediatric disability at St. Thomas’ Hospital in London, was given an OBE in 2015 for her work in child healthcare. She served as president of the Royal College of Paediatrics and Child Health from 2012 to 2015.
Dr. Hilary Cass worked at Great Ormond Street Hospital (GOSH) from 1994 to 2009 as a consultant in pediatric disability. She left Great Ormond Street Hospital in 2013 after raising concerns about patient safety. She was later elevated to the position of chief executive Dr. Jane Collins after providing a detailed explanation of her concerns about subpar staffing, low morale, and poor communication between departments.
The hospital agreed to settle their dispute and she brought them to court for constructive dismissal.
A regional centers should be able to provide “direct service providers, assessing and treating children and young people who may need specialist care, as part of a wider pathway,” according to Cass’ interim report from the Cass Review on March 10th, 2022.
