The Cass Review - Our initial review and actions

Last week Dr Hilary Cass published her Final Report following her review on gender services for children and young people in England. Our team is now reviewing the 400-page report and preparing the key questions that will need to be answered if we are to truly improve trans children and young people’s gender healthcare.

We firmly believe that trans children and young people deserve to be listened to and given access to the care and support that they need.

Securing their care and/or treatment, when they need it, is a top priority for Stonewall. These are vital services for children and young people, many of whom have been waiting for years for specialist care and support. This is totally unacceptable. It is a fundamental principle of the NHS that everyone should be able to receive treatment and care when they need it and children and young people have been badly let down in this regard.

With around 5000 children and young people waiting for care, and new referrals still not being given first appointments, what matters more than anything is having in place a clear plan of action, with funding, to build the capacity needed in the system to offer quality care and support in a timely way.

We welcome calls to develop a regional model of service delivery, but it is important that this commitment to expand capacity is not lost among the wider recommendations being considered – many of which also require additional resources.

While we work across the sector to develop a fuller analysis, we want to set out our questions and voice some initial concerns that need serious consideration if we are to truly improve trans children and young people’s experiences of gender healthcare as these recommendations are developed and implemented.

There are several places where the Cass Report has made statements or recommendations without fully explaining the policy intention or implications for providing clear conclusions on access to patient treatments. As Dr Cass observed, gender identity services are currently operating in a highly politicised context, unlike almost any other part of the NHS.

We are concerned that some clinicians will feel the chilling effect Dr Cass described, with some of these recommendations leading to children and young people being denied the care that they need. Further recommendations also pose questions as to whether healthcare for trans children and young people is being designed to different standards than those for other children and young people.

Immediate priority should be given to substantively responding to these issues to reassure the children and young people who are seeking to access these important services.

Our key areas of focus are:

• Resources and reform – The Cass Review makes significant recommendations on underpinning structure and resources to create modern, evidence-led potential models of care. These are welcome recommendations for a hugely underfunded and limited service. We want assurance that services will be fully funded to enable prompt access for children and young people who require care.
• Research – creating an evidence-led care pathway that delivers treatment in a way that is consistent with NHS models of care. We welcome a funding commitment to support research and development of services.
• NHS England Gender Service Development – ensuring the needs and rights of trans and gender diverse children and young people are respected and supported. It is important that children and young people have freedom and expression and can explore their sexuality and gender in a safe and supported way.
• Social Transition – ensure Dr Cass’ recommendations against a ‘blanket ban’ on social transitioning is fully implemented, communicated effectively and translated consistently across policy areas.
• 17-25 year olds – NHS care should be seamless and effective, regardless of your age or other characteristics. Protecting children and young people’s legal competence to make decisions informed decision about their care is key, as is protecting against unintended legal consequences across a whole range of services and well established rights.
• Puberty blockers and gender affirming hormones – ensure Dr Cass’ recommendations against a ‘blanket ban’ on puberty blockers is fully implemented, communicated effectively, and translated consistently across policy areas. A critical issue is that children and young people get the care and treatment they need assessed by a qualified medical professional. In some circumstances, puberty blockers may be the most appropriate treatment. This should be a matter of medical judgement based on the needs of the child or young person and informed by best medical practices and evidence.
• Access to NHS care – the NHS has always been free at the point of need, for everyone. Undermining this principle has serious consequences for everyone. There is risk that complex recommendations may unintentionally suggest anyone accessing private care due to excessive waiting lists or non-existent services is ineligible for NHS treatment, and that is unfair.

Resource and reform

Key proposals like creating regional services, improving clinical training and development, and designing new models of care and services are all positive developments.

Major reforms and the associated financial commitments are unlikely to be easily found in an NHS that is already over-burdened. Dr Cass stated in her interim report that ‘Doing nothing is not a neutral act’; it is important that safe, effective and timely provision is made for the children and young people that need healthcare urgently.

Stonewall will be working closely with our partners in children and young people, trans and LGBTQ+ charities to ensure that, however NHS England changes gender identity services, it does so by placing the needs and rights of trans and gender diverse children and young people at its heart.

Decision Making

We welcome the commitment to build a robust evidence base to inform healthcare services for trans and gender diverse children and young people. It is important that experts are fully engaged to ensure the evidence base for care is comprehensive and robust. We also welcome Dr Cass's recent clarification of the evidence considered in the review.

Beyond our concerns about building the capacity needed into these services, we are highlighting these key considerations at this stage:

• Social transition: Dr Cass has not called for adolescents to have their right to their identity or autonomy removed. Nor did Dr Cass recommend a blanket ban on social transitioning for children of any age. Most significantly, Dr Cass did not support unilateral ‘outing’ of trans young people by schools. There are clear gaps between recommendations and practical policy, and we’re already hearing early reports of Dr Cass’ analysis of – and recommendations about – social transition being used to challenge trans young people’s right to identity.

o Initial opinion: We are concerned that Dr Cass’ recommendations are being misrepresented in discussions around the draft guidance for schools and colleges in England on supporting ‘gender questioning children’, and may be misrepresented to justify restrictions on children and young people’s right to identity in school.

o Next actions: Along with our partners in the children and young people, trans, LGBTQ+, and children’s rights movements, we will continue advocating to the Department for Education for guidance that supports trans and gender diverse children and young people to thrive at school.

• 17 – 25s: There is a need for clarity about what a ‘follow-through' service for 17–25-year-olds means in reality. There are no immediately identifiable services available within the NHS, with many children and young people with a wide variety of needs often experiencing difficulties moving between children’s and adult services in the NHS and social care. Instead of setting out how a new service might work, NHS England announced an immediate further limit to access to support for 17-year-olds, including cancelling appointments for people who have likely been waiting years for support. These steps have already raised significant legal questions about restricting care both in terms of rights to treatment under the NHS Constitution and its underpinning legislation, trans young adults' human rights to health care, and potential discrimination based on age and other protected characteristics. Furthermore, there are legal risks and unintended consequences for young people's established legal rights to make informed decisions in line with the Gillick Competence and Fraser Guidelines.

o Initial opinion: We are concerned by NHS England’s interpretation and response, which has already led to restricted access to support for 17 year-olds.

o Next actions: Along with our partners in trans and LGBTQ+ charities we will work with NHS England to ensure that it does not lead to a sustained gap or block in support and care for a cohort of trans and gender diverse young people. We will advocate for an approach to this recommendation that ensures continuity of care for trans and gender diverse young adults and respects their autonomy.

• Puberty blockers and gender affirming hormones: The Cass Review Final Report argues that the evidence on puberty blockers is insufficient, but also acknowledges their efficacy for some trans young people. It recommends that more evidence be gathered through compulsory medical trials, which raises ethical concerns which will need to be addressed. Importantly, the Cass Review did not call for blanket bans on puberty blockers and this needs to be fully reflected in policy and service development with clear guidance issued at the earliest opportunity to prevent any blanket bans being implemented.

o Initial opinion: Dr Cass has now provided further clarity on the methodology used in the report which we welcome. We call for funding to support research and development in this important area. In a politicised decision-making environment, we are concerned that nuanced recommendations around their efficacy for specific groups will not be implemented, and that this will lead to blanket bans on hormones and puberty blockers, the treatment decisions for which need to be made in the best interest of the child or young person seeking treatment in line with recognised best practice for individual care.

o Next actions: We will call on NHS England to set out how children and young people who, based on a medical practitioners’ opinion, need puberty blockers will be prescribed them in a timely manner and reassure these individuals that they will not be waiting multiple years for multiple assessments to access this care.

• Private healthcare: There is an unclear recommendation that could be interpreted as suggesting that trans young people who access private healthcare should be prevented from accessing NHS treatment. Millions of people across the country use private healthcare and continue to benefit from full access to the NHS; it’s important to remember trans people often feel they have no choice because five year long waiting lists mean the NHS is failing to serve them in a timely way.

o Initial opinion: We are concerned that trans and gender diverse children and young people could be disadvantaged further for enduring long waiting lists for NHS care.

o Next actions: We will advocate to NHS England to ensure that trans young people will not be treated differently to the wider population and call on them to hold to the principle of the NHS that: “You're still entitled to free NHS care if you choose to pay for additional private care.”

What are our next steps?

Our teams will progress with their detailed review of the report and recommendations. We will continue to collaborate with our partners in children and young people, trans and LGBTQ+ organisations and those supporting trans children and young people to share our analysis and action plans. We will also seek advice and input from those with relevant specialist knowledge and expertise to inform our ongoing engagement.

Engagement with NHS England will be an important part of our ongoing work as will be wider engagement with decision makers to ensure improving the quality of life for trans children and young people remains central to their thinking and actions. Children and young people’s care and treatment is a fundamental human right and we are committed to ensuring that younger trans and gender diverse people get the care they need.