NHS to review all trans treatment
Evidence for letting children change gender built on shaky foundations, says Cass report
THE NHS will review all trans treatment, as a landmark report says that the evidence for allowing children and young people to change gender is built on “shaky foundations”.
Dr Hilary Cass, a paediatrician, today publishes her review into the support and treatment offered to children who believe they are transgender, and warns that extreme care should be taken before anyone under the age of 25 transitions.
It also calls for an end to the prescribing of any powerful hormone drugs to under-18s; warns that children who change gender may regret it; finds that many have experienced trauma, neglect and abuse; and says there is no “good evidence” on the long-term outcomes of treatments given to children.
The review warns of pressures on families, with parents feeling forced to allow their children to transition so they are not labelled transphobic.
Dr Cass declares that “gender medicine for children and young people is built on shaky foundations”.
In response, the NHS is to review all transgender treatment it provides, including for adults, and treatment for any new patients aged 16 and 17 at adult clinics will immediately be paused.
Rishi Sunak has welcomed the recommendations, highlighting the sharp rise in recent years in children, particularly girls, questioning their gender.
Backing Dr Cass’s call for all cases to be treated with “great care and compassion” he said: “We simply do not know the long-term impacts of medical treatment or social transitioning on them [children], and we should therefore exercise extreme caution.”
The 388-page report took four years to produce, amid mounting concern that children are being allowed to change gender in schools and by doctors without question.
Dr Cass, the former president of the Royal College of Paediatrics and Child Health, cautions against hasty decisions while children’s brains are developing, calling for “unhurried, holistic, therapeutic support” for those aged between 17 and 25. She adds that “life-changing” decisions must be properly considered in adulthood, noting that brain maturation continues into the mid-20s.
Dr Cass says that the regional centres recommended in her interim report, to provide mental health and other support to children who want to change gender, should care for people aged up to 25.
Dr Cass says the “toxicity of the debate is exceptional” and that she had been “criticised” by all sides. “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 urges.
In a letter to Dr Cass seen by The Telegraph, the NHS has said it will undertake an external review of all its adult gender clinics and has instructed them “to implement a pause on offering first appointments to young people below their 18th birthday”.
The letter, written by John Stewart, NHS England’s national director of specialised commissioning, said it would also “review the use of gender affirming hormones ... similar to the rigorous process that was followed to review the use of puberty suppressing hormones”.
Children’s clinics have been overwhelmed by referrals in the past decade, now receiving more than 1,600 referrals a year, compared with 50 in 2009.
An NHS spokesman said: “The NHS has made significant progress towards establishing a fundamentally different gender service for children and young people – in line with earlier advice by Dr Cass... by stopping the routine use of puberty-suppressing hormones and opening the first of up to eight new regional centres... We will set out a full implementation plan following careful consideration of this report.”
‘There should be a distinction for the approach taken to preand postpubertal children’
CHILDREN who think they are transgender should not be rushed into treatment they may regret, a landmark report has concluded.
The report by paediatric consultant Dr Hilary Cass has made 32 recommendations, including: calling for the “unhurried” care of those under 25 who think they may be transgender; an end to the prescribing of powerful hormone drugs to under 18s; and early help for primary school children who want to socially transition – which means using a name and pronouns of their preferred gender and being treated as though they are that gender.
The Telegraph has summarised the report’s key findings:
Last month, the NHS banned the prescribing of puberty blockers outside of clinical trials. However, Dr Cass has gone further and said children who think they are transgender should not be given any hormone drugs at all until at least 18.
The former president of the Royal College of Paediatrics and Child Health said there was no evidence the drugs “buy time to think” or “reduce suicide risk”.
While the drugs can suppress puberty, research commissioned by the review and carried out by the University of York found the drugs have no effect on the person’s body satisfaction or their experience of gender dysphoria – where the person feels they are a different gender to the sex they were born – despite this being the reason they had been prescribed.
Dr Cass stated there was “concern that [puberty blockers] may change the trajectory of psychosexual and gender identity development” with most patients going on to take cross-sex hormones as a result.
She said the NHS should exert “extreme caution” in giving out crosssex hormones to under 18s as the research carried out by her review concludes there is a “a lack of high-quality research” on their effectiveness. She said their use should be incorporated into the puberty blocker trial.
Dr Cass said all children and teenagers should be given time “to keep options open during this development window” and that this would allow time to diagnose and treat other conditions while preserving fertility.
She said doctors must be able to “refer to the longer-term benefits and risks” of treatment options but this was “not currently available” for children experiencing gender incongruence or dysphoria. A systematic review by the University of York of more than 1,000 children who had been treated by the Tavistock, found that 7.4 per cent of under-16s given puberty blockers stopped their treatment.
It found that the younger children started treatment, the more likely they were to continue on to cross-sex hormones, which means the drugs “are not buying time to think”.
It had also been suggested that the drugs could improve body image and psychological wellbeing – however, the review found “no changes in gender dysphoria or body satisfaction were demonstrated.”
Families should be able to see a medical profession such as a child psychologist or paediatrician as quickly as possible if a primary school child wants to socially transition, the report recommends.
Dr Cass states that while “exploration is a normal process” in teenagers, children who are yet to go through puberty will have been affected by “parental attitudes and beliefs”.
She states the importance of “avoiding premature decisions” and seeking help early on to understand the child’s behaviour and assess whether they are experiencing any mental health issues or distress.
Research conducted for the review found that prepubescent children who socially transition – which means a child being treated as their preferred gender, including using their chosen pronouns and name, and allowing them to use the facilities such as lavatories and changing rooms of their choice – were more likely to undergo medical treatment later.
She suggests that a “partial rather than full transition can be a way of ensuring flexibility and keeping options open until the developmental trajectory becomes clearer”.
“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.”
The report finds that “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.”
It recommends a clinical professional such as a mental health specialist “should help families to recognise nor
Parents feel forced to allow their children to transition so they are not labelled transphobic
Dr Cass said her review heard concerns from many parents about their child being socially transitioned and affirmed in their expressed gender without parental involvement.
Such cases often involved an adolescent who had “come out” at school while expressing concern about how their parent might react.
“Some parents felt ‘forced’ to affirm their child’s assumed identity or risk being painted as transphobic and/or unsupportive,” the report said.
In a small number of cases, there were concerns that parents were “consciously or unconsciously” influencing their child’s gender expression, it said.
“It is very important that the child/ young person’s voice is heard and that perceptions of gender identity represent the child/young person’s sense of self,” it said.
Under-25s should not be rushed into changing gender, but should receive “unhurried, holistic, therapeutic support”, Dr Cass concluded. She said “life changing” decisions must be properly considered in adulthood, noting that brain maturation continues into the mid-20s.
The report found that “clinicians are unable to determine with any certainty which children and young people will go on to have an enduring trans identity”. Young adults aged 17 to 25 who want to change gender should be seen by “a follow-through service” rather than sent straight to an adult clinic, the report concludes.
The NHS has been accused of fast-tracking thousands of teenagers to adult clinics, because they would not be seen before their 17th birthday, and prescribing them cross-sex hormones.
Dr Cass said these people were still at a “vulnerable stage in their journey” and that regional centres offering gender services for children, as well as mental health assessments and support, should care for those aged up to 25 or link up with such services.
The consultant paediatrician said it was not possible to “know the ‘sweet spot’ when someone becomes settled in their sense of self ” but that decisions should not be rushed before an individual becomes a mature adult at about 25.
“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?” she wrote in the report’s foreword.
The report said far more consideration should be given to reaching a point of maturity before taking a decision.
“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,” the review continues.
“The ‘future orientated’ prefrontal cortex matures later, with development continuing into an individual’s 20s, and … is concerned with executive functions such as complex decision making, rational judgement, inhibition of impulsivity, planning and prioritisation,” it states.
Childhood trauma, neglect and abuse feature heavily in the cohort of patients seeking gender changes, the report shows.
It cites a systematic review that found that in some services, as many as two thirds of those referred 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 had suffered from maternal mental illness or substance abuse while almost 40 per cent had experienced paternal mental illness or substance abuse.
An early study of UK cases referred to gender services found one quarter of children had spent some time in care. More than four in 10 cases had experienced living with only one parent, with almost as many having experience of family mental health problems.
The report shows that rates of mental ill-health have risen among children and young people, especially girls and young women.
This comes in parallel with the rising numbers seeking help from NHS gender clinics, where the biggest rise has been among those registered as female at birth, seeking help in adolescence to change gender.
Within this group, there are higher levels of neurodiversity and mental health issues, it says, calling for a “holistic” appraisal of the young patient, not solely in terms of their gender-related distress.
“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,” it states.
The report advises children expressing a desire to change gender are given time to think before being rushed into a decision they may regret.
It suggests that too many decisions about changing gender have been rushed, with too little consideration given that children might regret their actions in later life.
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.”
Evidence considered by the Cass review included talking to those who have transitioned to the opposite sex and those who have detransitioned back. 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.”
Data on the number of adults who have detransitioned are scarce, but the report said the number was “increasing”. A 2021 study found that 70 per cent of people detransitioning had another condition in the first place, while 23 per cent were actually gay, lesbian or bisexual.