On 10 April, the findings of the Cass Review were published in a 388 page document, and quickly gave rise to concerns from trans advocacy groups and charities.
But what is the Cass Review – and what does it say about gender-affirming care for trans youth? And, importantly, how has the trans community responded to its suggestions?
What is the Cass Review?
The Cass Review is an independent investigation into the provision of care to trans and non-binary youth and children and young people questioning their gender identity, or experiencing gender dysphoria, in England and Wales.
With work beginning in Autumn 2020, the report was commissioned in response to the increase in children and young people seeking referral to Gender Identity Services.
The review is headed up by Dr Hilary Cass – who, despite being a one-time president of the Royal College of Paediatrics, notably has no prior experience in paediatric gender-affirming care.
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Is this the first time Cass’s findings have been published?
This is not the first time that recommendations from the Cass Review have been publicly shared.
In February 2022, interim findings from the investigation were published.
These led to the closure of what was the UK’s sole Gender Identity Development Service (Gids) for trans youth, managed by the Tavistock and Portman NHS foundation trust in London, with the aim of cutting waiting times.
Cass’s provisional findings also led to NHS England’s decision in March 2024 to stop prescribing puberty blockers (medication which temporarily, and reversibly, halts the progression of puberty).
In July 2022, Cass wrote to NHS England to outline further advice on a proposed model for care for trans youth – encouraging a more “holistic and localised” approach and a transition from a single centralised clinic to multiple regional clinics.
Dr Cal Horton, a research fellow in Oxford Brookes’ Centre for Diversity Policy Research and Practice, wrote an academic paper raising concerns about preliminary documents published as part of the Cass Review.
In the article ‘The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children’, published in The International Journal for Transgender Health, Horton argued that the interim recommendations promoted cis-normative standards and ideals.
What recommendations does the Cass Review make?
With the full report now published, the final review’s contents have been at the centre of media coverage this week – but what do they actually say?
The final Cass Review makes a wide-ranging selection of points – 32, to be exact.
Some of the key recommendations include continuing to advocate for decentralised Gender Identity Services and the creation of a separate pathway for pre-pubertal children and their families/carers.
It also calls for holistic, individualised care plans for trans and gender diverse youth, as well as screening for mental health conditions and neurodiversity and recommends that a service is provided for those wishing to detransition. Additionally, it recommends another “follow-through” service for those aged 17 to 25.
While retaining the possibility of prescribing hormone therapy for adolescents aged 16 and 17, the report recommends “extreme caution” in doing so before the age of 18.
Some points included within the review appear to have been more widely reported on than others, particularly in media outlets which are sceptical towards trans healthcare and legislative protections.
These include claims within the report that there is a “lack of high-quality research” on the effects of long-term hormone use among young people.
Already, the Cass Review has been criticised by leaders in trans healthcare, including the Professional Association for Transgender Health Aotearoa (PATHA) who issued a statement criticising the lack of trans experts included in the report and raising concern about potential anti-trans bias.
“The final Cass Review did not include trans or non-binary experts or clinicians experienced in providing gender affirming care in its decision-making, conclusions, or findings,” the statement reads.
“Instead, a number of people involved in the review and the advisory group previously advocated for bans on gender affirming care in the United States, and have promoted non-affirming ‘gender exploratory therapy’, which is considered a conversion practice.”
PATHA also called into question the claims made in the review that there is insubstantial evidence supporting the efficacy of gender-affirming care.
“The [r]eview commissioned a number of systematic reviews into gender affirming care by the University of York, but seems to have disregarded a significant number of studies that show the benefits of gender affirming care,” it explains. “In one review, 101 out of 103 studies were discarded.”
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How has the UK Government reacted?
In response to the report, UK Prime Minister Rishi Sunak has urged “extreme caution” around the provision of gender-affirming care for young people.
Writing in the Daily Telegraph, Health Secretary Victoria Atkins has criticised a “culture of […] ideology” within gender services for youth.
“There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour,” she writes.
Following the release of the report, NHS England has stated that it intends to carry out a major review of its adult gender services and a review into the use of hormone therapy. It has also ordered adult gender clinics to pause inviting under-18s to any appointments.
Writing for The Guardian, trans journalist Freddy McConnell has warned that the further reviews which the Cass Review has triggered may be used to justify the scrapping of vital services for trans people.
“Now, reviews hang over us too – about us but no one knows to what extent with us – that may become Trojan horses for those who would roll back or perhaps eradicate affirming trans healthcare from the NHS altogether,” he writes.
What are LGBTQIA+ advocacy groups saying about the Cass Review?
Understandably, LGBTQIA+ advocacy groups and public figures are concerned about how the contents of the Cass Review are being perceived – and whether they could harm rather than help the trans community.
Trans youth charity Mermaids shared a statement to this effect, exploring how the recommendations in the report could be manipulated in order to restrict gender-affirming care.
“[We] are concerned that some of the language in the report is open to misinterpretation and could be used to justify additional barriers to accessing care for some trans young people in the same way the interim report has been,” the statement reads.
The charity also urged medical practitioners to centre trans voices at this moment of potential controversy and change. “[W]e call on NHS England, and the NHS across the UK, to resist pressures from those who seek to limit access to healthcare, listen to trans youth directly, and act urgently to provide gender services which are timely, supportive and holistic.”
The official statement from LGBTQIA+ charity Stonewall struck a similar note.
“Many recommendations could make a positive impact – such as expanding provision of healthcare by moving away from a single national service towards a series of regional centres, while recognising that there are many different treatment pathways that trans children and young people might take,” reads the official statement.
“But without due care, training or further capacity in the system, others could lead to new barriers that prevent children and young people from accessing the care they need and deserve.”
You can read the Cass Review in full here.
For further information about gender-affirming care and current recommendations in the field, please refer to the WPATH publications on standards of care.
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