The Cass Review Won't Transform Support for Trans Young People
In some, or many, ways, it might even get worse.
Summarising Dr Hilary Cass’ career, the Royal College of Paediatrics and Child Health says:
Dr Hilary Cass OBE is a consultant in Paediatric Disability at Evelina London Children's Hospital, Guy’s and St Thomas’ NHS Foundation Trust. She was President of the Royal College of Paediatrics and Child Health between 2012 and 2015, and was awarded an OBE in 2015 for services to child health.
[…]
Hilary is currently Senior Clinical Advisor to Health Education England, responsible for strategy on the development of the child health workforce. She continues to hold a series of education and management roles, both at Evelina and within the London School of Paediatrics. As part of her role at Evelina London, she is involved in development of new primary-secondary care interface and education models through the Children’s and Young People’s Health Partnership within Lambeth and Southwark.
It makes sense that a child specialist of her profile would be asked to lead this review.
The review was commissioned when Gender Identity Development Service (GIDS) started going up exponentially. This received a lot of criticism from campaigners who believed young people were being put on a conveyor belt and medically transitioned, with widespread regret. This feels unlikely. At the time of GIDS being mothballed, the time of waiting for an initial appointment was around 104 weeks. At the time of writing, only one of the eight regional networks which will replace GIDS is operational.
Cass maintains her review will stop children being treated as a political football, and work towards an evidence base for gender-affirming treatment. I am sceptical, however.
So, what’s your beef?
There are some big issues with this review:
The review missed an opportunity to centre the voices of trans young people who are languishing on waiting lists. Young people who are trans/gender-questioning without a doubt face some of the highest health inequalities in the country. A lot of them will need support from CAMHS that they will not receive—rejected because they are on a GIDS waiting list. A monumental multi-year investment is what is called for. The review missed an opportunity here.
How ‘evidence’ was conceptualised in this study was flawed. Maybe the biggest criticism is the exclusion criteria for inclusion in this review. The review stipulates that a lack of double-blind studies—studies where a drug is administered to a subject and neither the participant nor the researcher knows whether it is a placebo or real treatment—into the use of puberty blockers/gender-affirming drugs meant any evidence that their use improved outcomes was ‘shaky’. You can see why this might be the case. These types of drugs have really obvious side-effects. The study could not remain double-blind for long.
The exclusion criteria for research was unusual. This review also excluded any research that was not published in English, and systematic literature reviews—that is any expert from another country could not inform the outcome of this, despite citing international research and policies being a norm in policy-setting, and that researchers who had conducted systematic analyses themselves would be excluded from being included.
The proposal to create a national Multi-Disciplinary Team for considering putting older adolescents on a medical pathway is absurd. A brand new consultant will have usually trained for 13-15 years in total. We train them thoroughly so they can trusted to hold the risk for patients in their care. Part of this is that they use their extensive and specialised knowledge to prescribe drugs. Some of these may be ‘off label’ (not for their intended use) and this includes controlled drugs too. Endocrine drugs are not controlled. It is also not clear how this can happen in a timely way. That brings me onto…
The type of transformation needed to make these reforms work is unlikely. The review suggests that assessments for Autistic Spectrum Disorder should be sought, as well as mental health assessments. At present, the average wait for a first appointment for a child who is referred for this type of assessment is 42 weeks. An assessment of this type normally requires no fewer than three appointments in total. A young person is looking at a years-long wait—before they begin their years-long wait to explore their gender. Quite aside from this, it is generally accepted that people should have a right to choose whether they explore whether they are autistic or not. CAMHS and Community Paediatrics cannot meet their existing caseloads, without adding thousands of cases to the waiting list. This brings me to my final point…
Being trans is not something to be diverted away from. It is hard to escape this conclusion is somehow thematically where the review works from. The review wants stringent controls on social transition, on affirmation of any kind, before care can be accessed. It calls for an aversion to risk unlike anywhere else in medicine—that can only be construed as a way of delaying access to care at all.
Is it all bad?
Not really. There are some good ideas in the Cass Review, such as:
A service should be established to support young people who are considering de-transitioning. The rationale is that they may not want to return to previous services who supported their medical transition.
A new pathway should be created to ensure prepubertal children are prioritised for intervention. Timeliness is a key part of ensuring young people questioning their gender get the most appropriate care.
Fertility counselling and preservation should be offered before young people being placed onto a medical pathway. More comprehensive, holistic care should be a choice always, and better allays some of the concerns. I would, however, argue that these services should be optional.
Moving away from a single-provider model to a regional network model is overdue. Young people shouldn’t have to travel hundreds of miles to see a specialist. They should be able to see a specialist that is plugged into their local services if they so choose.
Can you help me?
I can try! I have worked with trans clients before to explore ideas around gender, and provide psychosocial education around —that might be wellbeing while you are waiting to see a gender specialist, or anything else. Get in touch:
Final thoughts
Services provided for transgender young people in this country have historically been woefully inadequate. Having a debate about their future is very welcome. Not all change is—what is clear however is that not all change is good.
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Thank you. Great assessment