How the Cass Review has reshaped care for transgender children, The Times 18.10.24

The original paywalled article is here.

On Monday, October 14, Hilary Cass swore an oath of allegiance to the King and took a seat in the House of Lords, almost six months to the day since she published a seminal report into NHS child gender services.

The retired paediatrician, now Baroness Cass of Barnet, had spent four years meticulously researching the most toxic and complex question in modern healthcare: how should we care for transgender children? The fact that she has emerged from the other side a universally respected crossbench peer is a remarkable testament to the impact of her 388-page report, which found no good evidence to support the prescribing of sex hormones to under-18s.

Six months on from the Cass Review, the medical landscape has been permanently reshaped: puberty blockers are illegal, the controversial gender clinic at the Tavistock has shut and new NHS services providing “holistic” care are up and running.

This is despite Cass having to contend with a wave of “misinformation” which, it can be revealed, largely originated in the United States and has been spread by groups including the British Medical Association (BMA). Cass believes the political backing for her report’s 32 recommendations have been crucial to its success, telling The Times this week that the “broad cross-party support means it didn’t become a political hostage to fortune”.

On Friday Wes Streeting, the health secretary, expressed his gratitude to Cass, saying her thorough evidence-based review meant that, at last, “we are taking politics out of children’s medicine”.

While Cass has commanded support from across the political spectrum and within the NHS, she has faced an unexpected backlash from an ideologically driven “vocal minority” of fellow doctors. A pocket of influential figures within the BMA attempted to halt the implementation of the Cass Review this summer by seizing on an error-strewn online paper published by academics and lawyers in the United States.

Its lead author is Dr Meredithe McNamara, a paediatrician who has argued that giving children puberty blockers is “one of the most compassionate things” a parent can do, and acts as an expert witness in US court cases arguing for gender-affirming care. This McNamara paper, which was widely shared online and fuelled an international backlash against Cass, has now been exposed as having a “significant number of errors and misrepresentations”.

n an article published this week in the Archives of Disease in Childhood, a peer-reviewed British medical journal, a group of leading paediatricians identified a series of unfounded claims, misrepresentations and factual errors in the US paper that underpins the BMA’s stance. They found the McNamara paper was “tailored for the courtroom” and written with the “primary purpose” of supporting lawsuits in the US, where the issue of gender medicine remains bitterly divided along party political lines and is settled through legal action. It warned that doctors should not use the flawed paper to “jeopardise the implementation of crucial reforms” in the NHS.

The lead author Dr Ronny Cheung, a paediatrician based in London, said the US report had been “very influential in swaying online discourse” and he was “very surprised” it was cited by the BMA, whose stance is at odds with the rest of the medical profession. “The overwhelming response from medical royal colleges, and politicians on both sides of the debate, has been to recognise the potential for the Cass Review to help us move things forward,” Cheung said.

Cass welcomed moves to debunk the critiques of her report. She said it had been “frustrating” to see her report misrepresented, but that “it is heartening to see respected clinicians and academics now feel able to challenge the misinformation”.

The BMA, meanwhile, has been forced into a partial climbdown and has now adopted a “neutral” stance, after more than 1,400 doctors signed an open letter expressing their “dismay” at the BMA for “going against the principles of evidence-based medicine and against ethical practice”.

While a bitter internal row rages within the doctors’ union, the NHS has remained committed to implementing Cass’s recommendations and ensuring children are not rushed on to a medical pathway. Her final report in April highlighted how distressed children must be seen as a “whole person and not just through the lens of their gender identity”, also receiving treatment for “ordinary” problems such as depression or autism. “The aim of many of the recommendations was to bring these young people back into mainstream care,” Cass explained, adding that the NHS is “making good progress”.

As part of this shift, the NHS has replaced the Tavistock’s controversial Gender Identity Development Service — which prescribed puberty blockers — with six new specialist clinics led by multidisciplinary teams. Two have already opened, at Great Ormond Street in London and Alder Hey in Liverpool, with a third due to open in Bristol next month.

Speaking to The Times, NHS leaders said the Cass review has been essential in providing a “backbone” around which new services could be built, despite a “toxic debate”. Dr James Palmer, the NHS medical director for specialised services, who oversees gender services, explained: “There is no other NHS service area where the views are so polarised as in children’s gender services.

“Having the Cass Review as the backbone for our plan means there is a solid touchstone that we can refer to as we set up new services. Two new specialist services have started already and we have a third opening next month, with more coming next year. For the NHS to quickly establish these services for one of the most complicated problems that faces healthcare, that’s fantastic. The feedback the first two clinics have had from patients and families is impressive. I’m optimistic that we’re getting this sorted.”

Meanwhile, the process by which children get referred for specialist gender care has been overhauled, after referrals increased 100-fold in little over a decade. Previously teachers, social workers and GPs could send children directly to the Tavistock; now children must be seen by a specialist who will assess for other issues such as mental-health problems or autism. Palmer said that closing off the “easy-access referral route into the Tavistock” may lead to an initial reduction in referrals to the gender services.

When her final report was published, Cass concluded that an entire global field of child gender medicine, including puberty blockers, was “built on shaky foundations”. The findings of her review reverberated around the world, and (unusually for an NHS-commissioned report) are now laying a new international foundation for a branch of medicine.

“The lack of evidence base leading to a change in the approach to gender care is not unique to England,” Cass said. “We are fortunate that our health system allows us to set up independent reviews that guide national policy, act on the evidence and implement improvement across the country.”

Cass said her review was “a starting point not an end point” and further research into treatments is essential. As part of this, an NHS clinical trial into puberty blockers will begin early next year.

Palmer said: “It looks very much like the NHS in England is going to be the world leader on producing the evidence base for this particular sector of child gender medicine, including puberty blockers.