NHS urged to drastically expand trans youth healthcare by independent review

NHS England to review puberty blockers and trans youth healthcare

An interim report from the Cass Review, commissioned by NHS England, has boldly suggested that having more than one service for trans kids in the entire country could be a good idea.

NHS England commissioned Dr Hilary Cass OBE, a former president of the Royal College of Paediatrics and Child Health, to conduct a review of healthcare for trans youth in the UK, it in 2020.

On Thursday (10 March), Cass released an interim report calling for regional centres to care for trans and gender-diverse youth across the UK “as soon as feasibly possible”.

There is currently just one NHS service which provides healthcare for trans youth in the whole of the UK – the Gender Identity Development Service (GIDS) at the Tavistock gender clinic in London.

Though the Cass Review is not yet making any final recommendations, its interim advice is this approach be overhauled, with local centres becoming “direct service providers, assessing and treating children and young people who may need specialist care, as part of a wider pathway”.

This expansion of services should include training for clinical staff at all levels, it added, as well as co-ordination between regional centres, and data collection to improve standards and treatment, something which is currently severely lacking.

“The review team will work with NHS England and stakeholders to further define the proposed model and workforce implications,” it added.

Cass Review offers no guidance on puberty blockers yet

The Cass review was initially designed to review clinical policies on the use of puberty blockers and hormone replacement therapy for young trans people.

It was later expanded to look into the rise in the number of young trans people seeking gender-affirming healthcare and to examine how such care can be improved, including how and when they are referred to specialist services.

Thus far, Dr Hilary Cass said, the review had heard from “a variety of experts with relevant expertise and those with lived experience to understand as many perspectives as possible”, and promised: “This listening process will continue.”

Complimenting this “listening process”, she said, will be the review’s academic research programme, which aims to provide “more detailed data and an enhanced evidence base”, in part to make recommendations on puberty blockers and hormone treatments for young people.

The report states: “The review is not able to provide definitive advice on the use of puberty blockers and feminising/ masculinising hormones at this stage, due to gaps in the evidence base; however, recommendations will be developed as our research programme progresses.”

Following completion of the review, for which no timeline has been announced, Cass and an independent expert group plan to issue recommendations on care for trans, gender diverse and gender questioning youth.

The interim report made clear that it “reflects a point in time”, and “does not set out final recommendations”.

In an initial analysis of the report, Jo Maugham, director of the Good Law Project, said it had “ducked the core issue” and “failed gender incongruent young people” by refusing to address the issue of choice and consent when it comes to puberty blockers.

In a Twitter thread, Maugham pointed out that Cass has declared that “doing nothing is not a neutral act”, meaning that choosing not to prescribe puberty blockers to a young person is as much of an impactful decision as prescribing them.

Addressing Cass’ assessment that “the evidence base on the use of puberty blockers [is] nevertheless is not strong enough” on “face value”, Maugham tweeted: “It’s not unusual for treatments to involve risks. And the way in which the medical profession resolves these questions is by inviting patients to examine those risks.

“It’s your life, right, not theirs, and so you get to choose.”

Maugham said that while the medical community may learn more about puberty blockers, this does nothing to answer the question of choice.

“The fact of her dodging that question, of kicking the can down the road (remembering she has already taken far, far longer than she promised to deliver even an interim report), will make it very difficult for the trans community to feel optimistic about where she will get to,” he wrote.

“If you are desperate to get puberty blockers, and you will be because not having them is not neutral, you will get them and the only question is how.

“What this means will be different for different socio-economic groups. Wealthy families will take their kids to private clinics abroad for a high quality wrap around service. Middle class families will construct their own patchwork of services, sub-optimally, using what they can buy affordably from private providers.

“Those from poorer backgrounds – and many whose parents are not affirming – will choose to buy drugs from the dark web, sometimes with hugely damaging consequences. And that’s just the reality.”

The Cass Review interim report acknowledged that there were several intended outcomes in prescribing puberty blockers, including “providing time/space for the young person to make a decision about continuing with transition”, “reducing or preventing worsening of distress”, “improving mental health”, or “stopping potentially irreversible pubertal changes which might later make it difficult for the young person to ‘pass’ in their intended gender role”.

It added that “proponents for the use of puberty blockers highlight the distress that young people experience through puberty and the risk of self-harm or suicide”.

Several studies have shown that puberty blockers improve mental health outcomes for trans children, including a study this month which found that gender-affirming care for trans youth such as hormone therapy and puberty blockers was associated with 60 per cent lower odds of moderate or severe depression and 73 per cent lower odds of suicidality over a period of one year.

Despite this, the Cass Review said that puberty blockers were “arguably more controversial than administration of the feminising/masculinising hormones, because there are more uncertainties associated with their use”.

“The review will seek to gain a better understanding of suicide data and the impact of puberty blockers through its research programme,” the interim report said.

The response to the Cass Review’s interim report from the UK’s trans community was largely made up of hesitant optimism mixed with deep concern.

Concerns ranged from the language used, to the focus on “diagnosis” as a precursor to support, to Dr Cass herself, who has no professional experience with trans youth and incidentally follows anti-trans lobby groups LGB Alliance and Transgender Trend on her personal Twitter account.

Anonymous advocate and parent of a trans child Fierce Mum, who gave feedback to a panel for the Cass Review, wrote on Twitter: “I feel deeply uncomfortable with any trans allies or trans supportive orgs in any way getting behind this report.

“Yes there are some things in there that everyone can agree on, that the current system is broken. But the pathologisation throughout makes me deeply concerned.”