(CP) The NHS will instruct "gender clinics to implement a pause" on first appointments for those under 18 after the release of a long-awaited review of how the government service treats youth with gender dysphoria.
The Cass Report, commissioned by the NHS in 2020 as part of an Independent Review of Gender Identity Services for Children and Young People, was released Wednesday.
Chaired by Dr. Hilary Cass, the retired former president of the Royal College of Paediatrics and Child Health, the report lays out the recommendations from the NHS England Policy Working Group as to practices medical professionals should follow when ministering to youth with gender dysphoria in the future.
Participants in the NHS England Policy Working Group include endocrinologists, psychologists, individuals who have experienced gender dysphoria, a child psychiatrist, an academic ethicist as well as several NHS employees.
The review was commissioned following the exponential increase in the number of youth seeking treatment for gender dysphoria over the past decade-plus, as well as concerns about the long-term impacts of prescribing puberty blockers and cross-sex hormones on trans-identified children.
"The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress," Cass wrote in an introduction to the report.
The report acknowledged that while many studies show that the use of puberty blockers for children with gender dysphoria is "beneficial in reducing mental distress and improving the wellbeing of children and young people with gender dysphoria," the "quality of these studies is poor."
The report urges the NHS to "review the policy on masculinising/feminising hormones."
Noting that "the option to provide masculinising/feminising hormones from age 16 is available," the review recommended "extreme caution" for prescribing cross-sex hormones to minors.
"There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18," the report adds.
In a Wednesday letter to Cass responding to the report, NHS England National Director of Specialised Commissioning John Stewart said NHS "will set out a full implementation plan, following full consideration of your final report, in due course, and this will include the detail and structure of our approach."
"In view of your advice about the need for caution in the initiation of medical interventions for young people under 18 years of age, our letter instructs the adult gender clinics to implement a pause on offering first appointments to young people below their 18th birthday," the letter reads. "This letter also makes clear that NHS England expects full cooperation from the [Gender Dysphoria Clinics] in the delivery of the data linkage study, on which we have corresponded separately."
NHS said it will "review the use of gender affirming hormones through a process of updated evidence review and public consultation, similar to the rigorous process that was followed to review the use of puberty suppressing hormones."
"In the meantime, you have made clear that the new providers should be 'extremely cautious' when considering whether to refer young people under 18 years for consideration of hormone intervention," the letter continues. "In order to support the providers in following your advice we have established a national multi-disciplinary team (MDT) that will review and need to agree all recommendations for hormone intervention."
The Cass report instructed the NHS to establish a research program to "look at the characteristics, interventions and outcomes of every young person presenting to the NHS gender services."
The research program should examine the "outcomes of psychosocial interventions and masculinising/ feminising hormones" in addition to providing a "follow-up into adulthood" for young people prescribed puberty blockers.
The report suggests that puberty blockers should only be obtained as part of a "research protocol."
Additionally, the report encourages the NHS to adopt an entirely different service model when it comes to treating children with gender dysphoria.
Under the current service model, gender clinics are "psychologically focused" with "separate but linked endocrine service." The report suggests implementing a multi-layered approach to treating children who experience discomfort with their biological sex.
The model proposed in the report involves the creation of multiple designated local specialist services designed to meet the "wider needs" of gender dysphoric youth as the first point of contact. The report envisions these centers as providing "a wide range of services, helping young people to overcome the psychological and social needs and challenges they might face," such as autism spectrum disorder and attention deficit hyperactivity disorder.
"The expansion of such models could support not only this population of young people, but also the wider population of children and young people presenting to the NHS," the report stated. The document repeatedly asserted that many of the young people presenting themselves with gender dysphoria have confounding psychological conditions that need to be addressed.
The new model would also include a smaller number of regional health centers that would "be responsible for managing the caseload of individuals requiring support around their gender identity and hold responsibility for the assessment and treatment of those with more complex presentations and requiring more specialist care."
Services provided by these facilities would include "mental health services, services for children and young people with autism and other neurodiverse presentations, and access to endocrinology services and fertility services, where appropriate for those seeking medical intervention."
"[A]ll children should be offered fertility counselling and preservation before going on a medical pathway," the report recommends.
The regional health centers would be linked to designated local specialist services via operational delivery networks created to ensure that youth with gender dysphoria have "access to supportive care and appropriate treatment as close to home as possible."
The model outlined in the report is headed by a "national provider collaborative" that establishes "the development of shared standards, operating procedures and clinical protocols, for example, for assessment and treatment."
Additional responsibilities of the national provider collaborative would include "updating the assessment framework in line with emerging evidence, audit and quality improvement, the development of clear referral criteria and intake procedures to ensure equitable access to services," and "a forum for discussion of complex cases and all decisions about medical care (a national multi-disciplinary team)."
The national provider collaborative would also oversee "an ethics forum for cases where there is uncertainty or disagreement about best interests or appropriate care" and work on research and the creation of a national dataset about youth with gender dysphoria.
Even before the final Cass report was published, the independent review authorized by the NHS has had implications on treatment for trans-identified youth in Britain.
Two years ago, following the publication of an interim report from Cass, the gender clinic at Tavistock and Portman NHS Foundation Trust in London that provided gender transition services for trans-identified minors in the U.K. was shut down in favor of a network of local clinics.
In October 2022, the NHS issued proposed guidelines stating that doctors shouldn't be so quick to promote social transitions for children with gender dysphoria because they may be going through a "transient phase."
In March, the NHS said it would stop providing puberty-blocking drugs for children with gender dysphoria except for when they are part of a clinical trial.
