To the NHS, Are you doing enough for Transgender Children? The Ongoing National (and International) Debate

Dr Hilary Cass, author of the Cass Review (‘the Review’), qualified in 1982 as a general paediatrician at Royal Free Hospital Medical School. Dr Cass has since specialised in paediatric disability and is renowned as an expert in her chosen field.

Dr Cass’s principal task in conducting her investigations and preparing her review (‘the Review’) was to produce recommendations for the most effective and appropriate way in which to provide care and support for the growing number of children and young people who are looking for support from the NHS in relation to gender dysphoria. It seeks to prevent the use of hormone blockers in young people and look at the evidence available to limit the number of people that go on to detransition.

In this article we will outline the findings of the Review that specifically concern the evidence and research quality, as well as outlining the backlash that has been issued by the University of Yale.

The purpose of the Review

The purpose of the Review was to provide an independent assessment of gender identity services for children and young people. providing recommendations for improvements in the way that the NHS treat and support the growing number of children and young people with gender identity issues of varying severity. The recommendations seek to help vulnerable people, but it is clear that the current service is unable to cope with the pressures and demands.  Although the Review’s laudable recommendations are intended to ensure that children and young people who are facing gender identity problems or gender dysphoria receive the best care package to meet their additional needs, the issue of resources will always be in the background.

Evidence and research quality

The Review criticised the evidence supporting the need for gender affirming care. The Review concluded that ‘while a considerable amount of research has been published in this field, systematic evidence reviews demonstrated the poor quality of the published studies, meaning there is not a reliable evidence base upon which to make clinical decisions’… ‘for children and their families’.

To provide better evidence, the Review commissioned a robust and independent evidence review and research programme from the University of York to inform its recommendations and remained cautious in its advice whilst awaiting the findings. The University of York’s programme highlighted that there is a lack of high-quality evidence for gender identity concerns and suggests that this is due to a lack of cooperation from adult gender services, highlighting lack of cooperation amongst services as an ongoing issue.

The consequent recommendation was to improve the evidence at the heart of the decision-making process in order to produce the best possible information with which to make decision that would have ling-lasting and life-changing implications.  Dr Cass stated that there is ‘remarkably weak evidence’. The existing studies overexaggerate findings in order to support a particular viewpoint, making the evidence that is available biased and unreliable. As a result of the weak evidence, the risks and benefits are misrepresented and there remains no reliable long-term evidence to manage gender-related suffering. For example, the Review asserts that ‘the percentage of people treated with hormones who subsequently detransition remains unknown due to the lack of long-term studies’. Dr Cass goes further, recommending the discontinuation of puberty blockers as standard practice for transgender children within the NHS due to the long-standing conflict with international standards of care.

University of Yale responds with criticism

In response, Yale Law School and Yale School of Medicine have argued that the ‘recommendations are informed by a flawed concept of evidence’. Professor Anne Alstorr and Dr Meredithe McNamara (along with a team of international experts) criticised the Review’s failure to define evidence quality, contravening the standard practice in scientific evaluation of medical research.

The Yale team also contends that the Review has misrepresented data and scientific method. In short, the review’s conclusions are invalid because Dr Cass failed to evaluate the evidence in a scientifically valid manner all whilst relying on ‘serious methodological flaws’.  

However, the Review has been widely accepted by UK politicians. The Health Secretary, Wes Streeting, has pledged to work towards implementing the recommendations as he feels that transgender people have been ‘utterly failed’ by the state of healthcare and feels an obligation to ‘get this right for them’. In addition, the Scottish Government has engaged with the findings of the Review and have paused the use of puberty blockers as a treatment for transgender youths across the Scottish NHS boards.

Concluding thoughts

Overall, the Review offers a roadmap towards providing more effective and evidence-based care packages for transgender and gender questioning young people.  It seeks to improve the outcomes for undeserved population whilst understanding the struggles between demand and availability. The Review provide a new, holistic and multi-faceted model of care, along with a better infrastructure and robust evidence-based information, in order to create the foundations for better decision-making and future success. However, as outlined by the Yale Report, not everyone agrees.  As the debate continues to unfold, the success rate of the recommendations and their implementation, and the overall effect on the treatment of gender dysphoria in the UK healthcare system (and beyond) will need to be reviewed again in the future.

Please access the full copy of the Cass Review via their website through the following link: Final Report – Cass Review.

Please access the full copy of the Yale Report via the following link: Microsoft Word - Cass Response.docx (yale.edu)