Cass review: how has report affected care for transgender young people? | Transgender

AThe heart of the controversy on how to meet the needs of young people questioning their gender was the enormous increase in references to Tavistock – before the only dedicated clinic in England and Wales, treating children with gender dysphoria.

The clinic was closed a month before the Cass Review in gender identity services for young people, commanded by the NHS England and led by the British pediatrician Hilary Cass, who found that the children had been “disappointed” by the NHS in the middle of a “toxic” public speech.

His report recommended a significant change in medical intervention treatment to a more holistic approach to care, including therapy and Treatment for coexisting Mental health problems, neurodivergence or family problems, and to be provided by a network of regional centers rather than focusing in the same place.

The Cass effect

Fourteen months later and the exponential increase in references for NHS care has stopped, the figures showing a strong reduction of up to 280 references per month to Tavistock to between 20 and 30 per month this year, a 10th of the previous rate.

James Palmer, the The medical director of specialized services at NHS England, who is responsible for the implementation of Cass recommendations, suggests that a number of factors are behind the decrease. Young people can now only be referred to the gender service for young people through mental or pediatric health specialists, rather than a general practitioner.

Palmer also thinks that the reduction is partly due to the “change of philosophy” brought by Cass on hormonal treatments. His examination concluded that there were “remarkably weak evidence” that puberty blockers (prescribed to give young people suffering from distress and dysphoria about their bodies to consider their next movement) and hormones between sex (which have masculinic or appearances of femininity) improve the well-being of young people and which concern their health.

Cass aroused the temporary ban on the use of drugs blocking puberty, which was extended indefinitely by the Secretary of Health, Wes Street, last December. Cross-sex hormones can be prescribed for children aged 16 to 18 in rare cases, but in practice, none has been since the exam.

“There is also an impact – completely immeasurable – of the change of position in this country and in the world,” adds Palmer. The journal Cass was clear, he argues that even the social transition is “not a neutral act” and that better information is necessary on the results for the children who do it, as well as support for parents and schools. “But there is also an impact on the global political environment which has become less to accept trans and young people who question the gender.”

Palmer, a neurosurgeon by background, says that waiting times for new hubs are “still really significant” and that it will take up to three years to cross the “substantial backward” inherited from Tavistock, and the services continue to face strong criticisms of young people and their parents.

According to NHS England, the waiting list of new hubs culminated in December 2024 at more than 6,400 and was reduced to just over 6,000. There are now three regional centers open in London, Bristol and northwest of England, with the ability to see around 25 patients per month, and a fourth should open its doors in the east of England this year.

Once the seven regional centers open, Palmer said: “We will arrive where we want, that is to say that individuals, as soon as that [gender] Inculture is starting to be really persistent, even at a young age, will be able to have access to an NHS service. ”

While opinion always differs on the best way to meet the needs of this vulnerable group of young people, the criticisms of what Palmer describes as a “change of philosophy” argues that the fall in references to the NHS services masks the real figures in search of intervention, many families turning to private providers and the hidden economy to access the drugs to help them live as a different genre.

Palmer accepts the long expectations of help “affect the way individuals approach their care and, of course, some take desperate measures to go to unregulated suppliers and search for hormones”.

A clinical trial of puberty blockers, recommended by Cass, is set up by an independent research team from King’s College London, which takes it by ethical and regulatory approvals.

A panel of experts will appear at Street in July after having considered a similar ban on transversal hormones for young people aged 16 to 18, with initial signals according to which an additional restriction is likely.

Long expectations and legal challenges

The Guardian spoke to a range of parents of their concerns about the treatment of their children since the publication of the Cass report.

Some have said that they had more hope since the accent put by Cass on evidence -based care and were delighted to see underlying problems highlighted in its report – such as intimidation, neurodiversity, emerging homosexual attraction and trauma – addressing regular sessions with a psychologist.

Others said that this culture change had not reached adult services, where older adolescents were treated, adding that they were the same cohort subject to the same societal factors that were examined by Cass.

Some parents were particularly frustrated that other European countries carried out similar examinations on the basis of evidence for hormonal treatments, but arrived at different conclusions that supported their use for young people.

They also feared that New Hubs staff do not seem to be very experienced in gender care, which they thought was a limited understanding of how critical decisions on hormonal treatment can be. The hormones’ ways affirming the sexes, for example, although technically still available were simply discussed.

A family reported that they had been warned by a center that access to private hormonal treatment could trigger a backup reference by their general practitioner and even a police report.

Another said that it was unfair that the NHS in England moved 200 young people who already receive a blockage of puberty or treatment affirming sex in Tavistock to a Nottingham clinic where their hormonal treatment continues, while other young people were not offered this option.

For Ben, 18, who lives in the midlands with his family and is about to start a diploma in a university of the Russell group, there is a “value” in holistic support, such as the priority by Cass. But he says that speaking therapies lose their value if young people feel that they must “prove themselves” deserving access to hormones.

Ben has joined the youth service waiting list at the age of 14, but was transferred to the NHS for adults’ waiting list earlier this year after being 18, never having had any appointments. Instead, his family came to puberty, then testosterone from an online clinic.

“I can understand that for someone who was not in my position, it is obviously a massive decision for a young person to take, and it is necessary to have guarantees in place, but completely delete access to hormones will have a negative impact on many young people for the rest of his life.

“While the use of unregulated private suppliers presents more risks than access to health care thanks to the NHS, the risk is much more important where trans Ins are left without any access to health care, as is the case for many of those who are unable to pay for private health care.”

Some young people formerly treated in the new hubs have found their way to the Sense Private Plus, a clinic that treats young people as well as adults, and is the only service in the United Kingdom able to prescribe inter-sex hormones to children from 16 to 18 years old, in accordance with the advice of NHS England thanks to its hormonal clinic registered in the quality of the quality of care.

Its director, Dr. Aidan Kelly, said: “I hear that there is an enormous abandonment rate [from the new hubs]This does not surprise me because the basis of evidence of group therapy helping young people suffering from dysphoria between the sexes is lower than that of hormonal interventions. They believe that the NHS has abandoned them and that they are waiting to age in the service for adults. »»

The adult service is under examination by the NHS England, in response to the detailed concerns raised by Cass following its examination of young people, including “out of control” waiting lists, inadequate consent processes and a limited explanation of the risks linked to treatment.

In 2024, the first full year of Gender Plus, it took 874 references, 343 of which were under 18, and it extended to sites in London, Birmingham, Leeds and Dublin, with 20 employees, many of whom worked before at NHS Gender Services. Of the 16 to 18 year olds, 61% were prescribed hormones claiming the sexes after finishing the average of six months of evaluation.

Sex Plus faces a legal examination at the end of June, brought by the former specialist in the genus of the NHS, Sue Evans, who also launched procedures against Tavistock in 2019, contesting the CQC decision to grant the Hormone Clinic to Gender more in December 2024 after his first inspection.

Kelly suggests that the NHS England supposed by refusing young people access to medical routes, they simply “abandon”.

“There is no evidence of what happens and in fact there is evidence that it hurts.”

Last year, The Guardian reported experts warning that the growing number of under the age of 18 turned to the hidden economy of drugs. Some of these young people become politically active. In March, the group of Trans Kids activists better deserves a Guardian event with Street, stressing that he had not consulted the young Trans before making decisions concerning their treatment, but had spoken to other groups which opposed the care affirming the sexes.

The NHS in England says that the most cautious approach approved by Cass includes regular meetings with a clinician and a series of therapy options, one by one, in groups and family, as well as treatment for coexisting mental health problems, including drugs if necessary.

During the construction of new services, efforts were made to let the clinicians continue their day work far from media spotlights. But Palmer says that he is worried that “polarized debate in newspapers” does not recognize that there are many young people “who are really affected by dysphoria and distress that can follow the incongruence between the sexes and need access to the care of an NHS service”.