Clinical decisions for gender questioning children lack evidence base, expert review concludes

Children and young people struggling with gender-related distress must be given holistic support, not just care linked to their gender identity, the review of gender identity services in England has concluded.

The review, chaired by Dr Hilary Cass, said there was a lack of reliable evidence on which to base clinical decisions relating to gender identity, or for children and their families to make informed choices.

And it warned the rationale for using so-called puberty blockers “remains unclear” and the  controversy over medical treatment had “taken focus away” from individualised care.

The review was commissioned by NHS England following concerns about the rising number of children and young people questioning their gender identity and seeking support for gender dysphoria, leading to a spike in waiting times.

While the review focused entirely on gender identity services within NHS England, it will likely have implications for services in Scotland.

The Scottish Conservatives have urged the Scottish Government to instigate a review of gender clinics in Scotland and to pause the use of puberty blockers, a step already taken in England. 

In her review, Cass calls for services to operate to the same standards as other services which treat children and young people with complex problems.

Those who present to NHS gender services must receive an individualised care plan, she concluded, which should include screening for neurodevelopmental conditions and a mental health assessment.

Cass said: “It’s important to remember that at the centre of the review are children and young people who are in a developmental phase of life but the decisions they need help to navigate may have life-long implications.

“The central aim of gender care should be to help young people to thrive and achieve their life goals. The immediate goal must be to address distress and any barriers to participation in everyday life.

“What I am recommending is an expansion of capacity distributed across the country, grounded in paediatric services and delivered in a consistent way; a much more holistic offer of care that considers the child as a whole person and not just through the lens of their gender identity; and the development of a robust research environment to provide evidence on long-term outcomes and efficacy of different interventions so that future care is informed by robust evidence – evidence which is sorely lacking at the current time.”

An interim report by Cass already led to the closure of a centralised, specialist gender identity service in London, known as The Tavistock Centre, while new regional hubs have been opened.

And new NHS guidance last month means puberty blockers – which pause the physical changes of puberty – will no longer be prescribed to children in England except as part of clinical research trials.

NHS Scotland has not followed suit. Health secretary Neil Gray said that the new rules were “being closely considered by NHS Greater Glasgow and Clyde, as the provider of the young people’s gender service at Sandyford, and its relevant clinical team”.

He added: “Any decision on how such healthcare is delivered in Scotland will rightly be made by health boards and their clinicians.”

Cass’s latest review concludes that the rationale for puberty suppression “remains unclear, with weak evidence regarding the impact on gender dysphoria, mental or psychosocial health”.

It adds: “The use of masculinising/feminising hormones in those under the age of 18 also presents many unknowns, despite their longstanding use in the adult transgender population. The lack of long-term follow-up data on those commencing treatment at an earlier age means we have inadequate information about the range of outcomes for this group.”

Cass calls for the use of masculinising or feminising hormones to be included in the programme of research on puberty blockers, and adds that any decision to prescribe such hormones to those aged 16 and 17 should be made with “extreme caution” and have a “clear clinical rationale”.

Other recommendations in the review included expanding capacity of services across England; establishing separate pathways for pre-pubertal children; creating follow-through services for 17-25 years olds; and support for people considering detransition.

Scottish Tory deputy leader Meghan Gallacher said: “While there is a lot of information to digest in this report, one of the most damning conclusions is that children have been let down. This is simply unacceptable.

“If the SNP won’t heed the recommendations made by the Cass review then they must urgently undertake their own evaluation so that we can protect the wellbeing of young people, especially children, accessing these services, starting with pausing the use of puberty blockers.”