Cass Review highlights shocking failures in gender identity services

The Final Report into NHS’s England’s gender identity services has been published. It is a devastating and at times damning report which clearly shows that ideology has been allowed to take precedence over evidence, rather than the other way round. It is an independent report and the chair of this independent review was Dr Hilary Cass.

From a Christian perspective, the most fundamental reality when it comes to debates around gender transitioning is the protection of vulnerable children. In the Christian worldview, all children are made in God's image. They all be treated with love and dignity. God made us male and female. We are different and distinct, but have equal value. Biological sex is a key part of human identity. Our bodies matter to God.

There is a clear rationale for exercising extreme caution over any transitioning with a belief that it is better to help children live in their God-given biological sex.

This report highlights significant and repeated failures to protect children and young people from harm. Moreover, the Report also shows how approaches to social transitioning have changed from a historic non-affirmative approach, to one where all too often, young children have been prescribed experimental, life-changing treatments without proper checks or data showing what the consequences might be. This change in treatment has happened despite a lack of evidence and gaps in data.

In other words, experimental forms of treatment have been used on children. When you let this sink in, you wonder how we ever allowed this to happen.

This article sets out some of the most salient and key points from the final report. Our prayer has to be that it will be listened to and appropriately implemented. Both main political parties in England have responded by saying work would take place to make sure the recommendations are brought in. Let’s hope and pray this happens but more importantly, that it happens alongside a wider rejection of damaging gender ideology.

Gender incongruence: A marked and persistent incongruence between an individual’s experienced gender and the assigned sex.

Gender Dysphoria: clinically significant distress or impairment of function.

The Cass Review was commissioned by NHS England in 2020. Its remit was to look at gender identity services for under-18s. This was in response to a sharp rise in the number of patients referred to the NHS who were questioning their gender.

This trend began in 2014, when referral rates to Gender Identity Development Services (GIDS) started to rise exponentially. The majority of referrals were biological females in their early teens. Data from the Final Report shows that between 1 April 2018 and 31 December 2022, the youngest child referred was 3 years old, the oldest was 18 and the mean and median age was 14. 73% were biological females, and 27% were biological males.

Shockingly, between 2009 and 2021, there has been 100-fold increase in the prevalence of gender dysphoria in people aged 18 and under. There was a gradual increase from 2009-2014 and then a huge acceleration from 2015 onwards. This exponential rise is mirrored in other, western and developed countries.

NHS England is responsible for specialised gender identity services for children. GIDS was managed by the Tavistock and Portman NHS Foundation Trust. The Tavistock clinic was rated 'inadequate' by inspectors following concerns raised by whistle-blowers. It was due to close in March 2024 and has been mired in criticisms and court cases.

Prior to this Final Report, An Interim-Report was published by Dame Hilary Cass in 2022. It criticised GIDS over its failure to consistently collect relevant data. It said its approach ‘has not been subjected to some of the normal quality controls that are typically applied when new or innovative treatments are introduced.’ The review also said a new model was needed, one that moved towards regional hubs, rather than one central, specialist clinic. One area the interim report did not make any recommendations over was the highly controversial use of puberty blockers for children.

Sum­mary of Final Cass Report Findings

Now the full and final Cass Report has been published. In short, it is highly critical of the way that NHS England has been treating children presenting with evidence of gender dysphoria. At times, the report is especially damning, including criticism in the following areas:

• A lack of strong evidence for some of the treatments used. This includes a failure to reliably collect even the most basic data and information in a consistent and comprehensive matter. Data has also often not been shared or been available.
• A lack of evidence over the short-medium-long term impacts of all clinical interventions.
• There are notable dangers surrounding social transitioning (this is where a child is treated as their preferred gender in terms of name, clothing choices etc...). Children should be given therapy before they are allowed to socially transition.
• Caution around treatment for all under-25s who should receive 'unhurried' care.
• Puberty blockers should not be given to anyone under 18. There is no evidence they do 'buy time to think' or 'reduce suicide risk'.
• A complex web of factors is behind the huge rise in children, especially females, presenting with gender incongruence / dysphoria, including increased mental health problems, neurodiversity, social media and the availability of pornography.
• There has been a failure of GIDS and NHS adult gender services to cooperate with the Cass Review, thereby leaving crucial gaps in relevant data.
• The report strongly criticises NHS England’s decision to make masculining/feminising hormones available from the age of 16. The review urges an ‘extremely cautious clinical approach’ and only giving them to under 18s when there is a strong, clinical rationale for doing so.
  

Key extracts from the final report

What follows is by no means exhaustive. But it gives a clear flavour of the depth of criticism from the Cass Final Report.

Purpose of the Report

• The aim of this Review is to make recommendations that ensure that children and young people who are questioning their gender identity or experiencing gender dysphoria receive a high standard of care. Care that meets their needs, is safe, holistic and effective. At its heart are vulnerable children and young people and an NHS service unable to cope with the demand.
• We have to start from the understanding that this group of children and young people are just that; children and young people first and foremost, not individuals solely defined by their gender incongruence or gender-related distress.
• Young people’s sense of identity is not always fixed and may evolve over time… Whilst some young people may feel an urgency to transition, young adults looking back at their younger selves would often advise slowing down.

Lack of clear evidence to support treatment

• To scrutinise the existing 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 finding. The University of York’s programme of work has shown that there continues to be a lack of high-quality evidence in this area and, disappointingly, as will become clear in this report, attempts to improve the evidence base have been thwarted by lack of cooperation from the adult gender services.
• There remains diversity of opinion as to how best to treat these children and young people. The evidence is weak and clinicians have told us they are unable to determine with any certainty which children and young people will go on to have an enduring trans identity.
• It has been suggested that hormone treatment reduces the elevated risk of death by suicide in this population, but the evidence found does not support this conclusion.

Puberty blockers

• Moreover, given that the vast majority of young people started on puberty blockers proceed from puberty blockers to masculining/feminizing hormones, there is no evidence that puberty blockers buy time to think, and some concern that they may change the trajectory of psychosexual and gender identity development.
• No conclusions can be drawn about the impact on gender dysphoria, mental and psychological health or cognitive development. Both health and height may be compromised during treatment.
• The dramatic increase in presentations to NHS gender clinics from 2014, as well as in several other countries, coincided with puberty blockers being made available off protocol and to a wider group of young people. The only country with an earlier acceleration in referrals is the Netherlands, where the Dutch protocol was developed.

Reliance on poor quality guidelines

The University of York identified 23 guidelines published between 1998 and 2002 that included recommendations about children, young people and gender dysphoria (four international, three regional and 16 national). These were assessed in terms of quality using the AGREE II model. This is the most commonly applied and comprehensively validated appraisal tool. It looks at: scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability and editorial independence.

Of the 23 guidelines, four did not provide any information about the development process, so were not appraised. All the remaining guidelines were appraised by three independent reviewers.

• For many of the guidelines it was difficult to detect what evidence had been reviewed and how this informed development of the recommendations. For example, most of the guidelines described insufficient evidence about the risks and benefits of medical treatment in adolescents, particularly in relation to long-term outcomes. Despite this, many then went on to cite this same evidence to recommend medical treatments.
• The guideline appraisal raises serious questions about the reliability of current guidelines. Most guidelines have not followed the international standards for guideline development (AGREE Next Steps Consortium, 2017). Therefore, only the Finnish (2020) and the Swedish (2022) guidelines could be recommended for use in practice.

Families must exercise caution

• It is possible that social transition in childhood may change the trajectory of gender identity development for children with early gender incongruence.
• The clinician should help families to recognise normal developmental variation in gender role behaviour and expression. Avoiding premature decisions and considering partial, rather than full transitioning can be a way of ensuring flexibility and keeping options open until the developmental trajectory becomes clearer.

Toxic culture silencing views

• 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. This must stop.
• Some practitioners abandoned normal clinical approaches to holistic assessment, which has meant this group of young people have been exceptionalised compared to other young people with similarly complex presentations.

Prevalence of autism and other neurodiversity

• Some research studies have suggested that transgender and gender-diverse individuals are three to six times more likely to be autistic than cisgender individuals, after controlling for age and educational attainment. These findings are echoed by clinicians who report seeing teenage girls who have good cognitive ability and are articulate, but are struggling with gender identity, suicide ideation and self-harm. In some of these young girls the common denominator is undiagnosed autism, which is often missing in adolescent girls.

Adverse childhood experiences

• The systemic review (Taylor et al: Patient characteristics) highlighted the fact that relatively few studies reported on adverse childhood experiences (ACEs), but those that did demonstrated high rates amongst children and young people referred to gender services.
• (For example: 11-67 % combined neglect or abuse; 53% and 49% maternal mental illness or substance abuse; 23-25% exposure to domestic violence; 15-20% physical abuse).
• Regardless of change in demographics, adverse childhood experiences and broader adversity within the family unit are important issues to be aware of when assessing young people’s needs and planning a support package for them.

Online Stressors and harm

• Several longitudinal studies have found that adolescent pornography consumption is associated with subsequent increased sexual, relational and body dissatisfaction (Hanson, 2020).
• The increase in presentations to gender clinics has to some degree paralleled this deterioration in child and adolescent mental health. Mental health problems have risen in both boys and girls, but have been most striking in girls and young women. In addition to increasing prevalence of depression and anxiety, presentations of eating disorders and self-harm have increased since the Covid-19 pandemic (Trafford et al., 2023).

His­tory of Gender Iden­tity Services

Services for children and young people with gender incongruence started in the mid-1970s in Canada and in 1987 in the Netherlands. In the UK, the Gender Identity Development Service (GIDS) was first established in 1989 by Domenico Di Ceglie in St George’s Hospital in London. It then moved to The Tavistock and Portman NHS Foundation Trust.

The initial focus was on therapeutic work with children and families. Only a small number of those with persistent gender incongruence were referred for hormone treatment from around age 16.

Then the emergence of the ‘Dutch Protocol’ changed how treatment for people with gender incongruence was done.

This was developed by Dr Peggy Cohen-Kettenis. In 1998, a single case study (Cohen-Kettenis and Van Goozen, 1998) described the female to male transition where puberty blockers were started at age 13. There was a two-fold rationale: first, to support the diagnostic procedure by buying time to think and secondly to improve the longer-term ability to live in the preferred gender.

In 2011, a Dutch team published a study of 70 patients who had received early treatment with puberty blockers between 2000 and 2008. Of the 70 patients, 89% were same-sex attracted to their birth registered sex, with the rest being bisexual. Only one was heterosexual.

The trial showed that there was no change in body dysphoria as a result of puberty blockers, although some behavioural and emotional problems were reduced.

But not all participants completed questionnaires after treatment. All patients also saw a psychiatrist or psychologist on a regular basis. This means it is difficult to know what was the result of the therapy and what was the result of the puberty blockers.

By this stage, there were two approaches to treating gender incongruence and dysphoria:

1. Assume a young person’s brain is malleable and therefore, the treatment goal can include helping a young child accept their gender matches their biological sex assigned at birth.
2. Assume children may have knowledge of their gender identity at a young age but should wait until at least adolescence before engaging in any full transition from one gender to another.

A third model emerged from 2007 onwards. This was a more explicitly ‘affirmative’ model. This approach allowed that a child of any age may know their ‘authentic identity’ and would benefit from social transition at any stage of development.

Since 2007, this third approach has become the dominant model.

In the UK, the ‘watchful waiting’ approach continued until 2011. Then a trial of puberty blockers took place. It was an uncontrolled study. Between 2011 and 2014, 44 patients aged 12-15 were recruited. The UK’s preliminary findings did not demonstrate improvement in psychological wellbeing.

Despite this, from 2014, puberty blockers moved from a ‘research-only’ protocol, to being available as part of routine clinical practice. The Cass final report states the ‘rationale for this is unclear’.

It goes on to say: “One of the problems that has been exposed is the governance of innovative clinical practice. Whilst care cannot improve without innovation, good clinical governance should require collection of data and evidence with appropriate scrutiny to prevent the incremental creep of new practices without adequate oversight.”

Con­clud­ing Reflections

The main reflection on reading and digesting the report is shock at why and how this was allowed to happen.

What is striking is the history of gender identity and development services. The West has shifted from a highly cautious approach to an overly affirmative approach. This coincides with moves towards a more therapeutic culture and one where identity has become seen as more fluid.

It shows you what happens when objective truth is replaced by subjective feelings. It is surely one of the great strengths of Christianity that it relies on revelation from outside of ourselves! If God is your starting point and it is His law that governs human reality, then we have an objective standard and crucially, one that does not change (because it is a reflection of God’s character which cannot change!).

What we see from God’s word is that He made them male and female (Gen 1:26-27). We are different and distinct, but equal in dignity and value.

This foundational, objective reality gives us our starting point to responding to the reality of gender incongruence and gender dysphoria. Our goal should be to be patient, to be compassionate and loving and to help individuals live within their God-assigned, biological sex.