Everything you need to know about the Cass report (2024)

An eagerly-awaited review into the care of gender-questioning children in England and Wales today tore apart current practices.

Dr Hilary Cass's near 400-page report states children have been let down by a lack of research on medical interventions like powerful puberty blockers.

And guidelines for treating children who want to swap gender also aren't evidence-based, therespected paediatrician said.

Her catalogue of damning findings will be used as ammunition to overhaul one of the most controversial areas of modern medicine both in the UK and the rest of the world.

Here, MailOnline, answers your questions on the Cass report, from what it found, what the next steps are, to how it started in the first place.

What did the Cass report broadly find?

The major review of care for gender questioning youth in England found youngsters were being let down by alack of research and evidence on the medical interventions that had become standard in the field.

As Dr Cass herself bluntly put it, the entirety of gender medicine for young people is 'built on shaky foundations'.

These included the use of controversial puberty blockers, which pause the physical changes of puberty such as breast development and facial hair growth.

It also took aim at the evidence, or lack thereof, on social transitioning, where a child is treated as if they had switch genders, for example changing pronouns and the use of cross-sex hormones in teenager.

Among the report’s 32 recommendations are a call for gender services to operate 'to the same standards' as other health services for children and young people, with 'a holistic assessment' of people referred.

Such a holistic approach would include screening for neurodevelopmental disorders such as autism, and a mental health assessment.

The Cass report also urged the NHS to change some other standards of its gender care.

This includes a review of its policy on giving children masculinising or feminising hormones from the age of 16, with the report urging 'extreme caution'.

Dr Cass said there 'should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18'.

The use of such hormones, the review said, should be part of a research programme alongside a previously reported puberty blocker trial which is expected to be in place by December.

What did it say specifically about social transitioning?

Dr Cass's report also warned a 'more cautious approach' must be taken for children than for adolescents when it comes to social transitioning, which is where someone might change their pronouns, name and/or clothing.

When families are making decisions about social transitioning, it is important 'parents are not unconsciously influencing the child’s gender expression', the review said.

It added thatthere was no clear evidence that social transition in childhood had any positive or negative mental health outcomes.

But it noted that 'those who had socially transitioned at an earlier age and/or prior to being seen in clinic were more likely to proceed to a medical pathway'.

Has there been any reaction to report?

Responding to the report, NHS England said it had written to local NHS leaders to pause first appointment offers at adult gender clinics to young people before their 18th birthday, and is 'bringing forward its systemic review of adult gender services'.

More broadly, the health service said it was 'very grateful to Dr Cass and her team for their comprehensive work on this important review', and that it would 'set out a full implementation plan following careful consideration of this final report and its recommendations'.

Most trans rights groups have not yet seen the report, but the findings and concerns highlighted are likely to be disputed by some.

Robbie de Santos, director of campaigns and human rights at LGBTQ+ rights organisation Stonewall, had a mixed response.

'What is important, above all, is that trans and gender-diverse children get the quality healthcare that they need and deserve,' he said.

'The Cass Review can play a vital role in achieving this aim if its recommendations are implemented properly.

'Many recommendations could make a positive impact – such as expanding the 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 young people might take.

'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.'

Dr Cass herself, perhaps anticipating some negative reaction, included the following notes in the report itself.

She insisted her review was 'not about defining what it means to be trans, nor is it about undermining the validity of trans identities, challenging the right of people to express themselves, or rolling back on people’s rights to healthcare'.

Instead, and addressing gender questioning children directly, she said: 'I have been disappointed by the lack of evidence on the long-term impact of taking hormones from an early age; research has let us all down, most importantly you.'

What do other doctors think?

Medical experts have broadly welcomed Dr Cass's findings.

Dr Lade Smith, president of the Royal College of Psychiatrists, said: 'Dr Hillary Cass has published a rigorous independent review.

'Crucially, it is informed by the views of people with lived experience, but also a broad range of views from stakeholders, healthcare professionals, social workers and of course, parents.

The College will now review, in detail, the recommendations of this important report and what they mean for patients, psychiatrists and mental health services. Once this work is complete, we will respond in full to its findings.'

Professor Steve Turner, president of the Royal College of Paediatrics and Child Health (RCPCH), said the review was a 'massive undertaking' and the college will 'closely consider the report’s recommendations'.

'It is essential that NHS England now provides the necessary additional guidance and support needed for paediatricians and the wider child health team to undertake their important role of caring for children who are gender questioning or experiencing gender dysphoria,' he said.

Professor Ashley Grossman, an expert in endocrinology at the University of Oxford said the new report shone a much-needed light on the use of puberty blockers in gender care.

'For many years we have been using puberty blockers in young children who are going into early puberty to delay puberty to a normal time – this has been very successful with much detailed evidence,' she said.

'This is a different situation – this set of reviews is looking at using these drugs to delay normal puberty.

'This very detailed set of analyses now suggests that there are not enough good data showing the long-term effects in children with gender dysphoria.

'More carefully run clinical trials are needed so that we can understand how and when such agents are justified and of benefit.'

Some charities have also welcomed the findings.

These include The Children’s Society, a charity allied to the Church of England which called it a 'watershed moment'.

Mark Russell, the charity's chief executive said: 'Children and young people exploring their gender identity still face unacceptable barriers in getting the support they critically need, highlighting that there are numerous oversights in how gender identity services are currently designed and delivered.

'This report should mark a watershed moment; an opportunity to dismantle the existing barriers and foster an environment which places the wellbeing and safety of all children at its heart.'

What happens now? Are NHS gender care services for children still running?

Gender care services for young people in England and Wales will continue as usual, while the NHS considers the Cass report.

Just weeks before final report came out, the NHS restricted the use of puberty blockers citing a lack of evidence on their 'safety or clinical effectiveness'.

However, NHS England's decision is not an outright ban on the puberty blockers completely.

Some 100 children currently on the drugs via the NHS will be allowed to continue their treatment to its conclusion and there are plans, as supported by the Cass report, for a clinical trial in their use in the future.

Additionally, in a sign of changes being underway the NHS's old Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust shut its doors two weeks ago.

This was followed by two new regional hubs opening in London and the north of England in an effort to move away from a single-service model.

NHS bosses hope to open seven or eight such centres in the future.

Will the report change how private gender clinics operate?

No, at least not directly.

As they are not under NHS purview, private clinics in England can still dish out puberty blockers and hormones to children as they have done in the past.

However, the Cass report's findings on a lack of evidence on the safety and effectiveness of such treatments will likely be used by campaigners who are calling for such private gender clinics to be restricted.

The review itself has stated that no GP should be expected to 'enter into a shared care arrangement with a private provider' if a young person has been given access to puberty blockers via that route.

It added GPs had 'expressed concern about being pressurised to prescribe hormones after these have been initiated by private providers and that there is a lack of clarity around their responsibilities in relation to monitoring'.

Dr Cass said the Department of Health and Social Care and NHS England must 'consider the implications of private healthcare on any future requests to the NHS for treatment, monitoring and/or involvement in research'.

Her review also noted that a young person’s eligibility to take part in the NHS study into puberty blockers could be affected if they took puberty blockers provided by an external source.

Is the report for England and Wales only?

Yes, the report was commissioned by NHS England which also runs gender care services for under 18s in Wales.

Therefore, gender care services in other parts of the UK, like those in Scotland,are not in its purview.

However, it will likely be referenced in debates about those services in the future.

Indeed, Northern Ireland has already said it will follow England's lead on the use of puberty blockers following the announcement of the change last month.

How did the Cass report get underway?

The Cass report was commissioned by NHS England in September 2020 to makerecommendations about NHS services for gender-questioning children and young people.

It was led by Dr Hilary Cass, former president of the Royal College of Paediatrics and Child Health.

NHS England said at the time that the review has been established 'in response to a complex and diverse range of issues'.

One of these was a massive surge in referrals to the NHS Gender Identity Development Service (GIDS) over the previous decade.

Referrals for GIDS, hosted at the Tavistock and Portman NHS Foundation Trust, went from just under 250 in 2011/12 to more than 5,000 in 2021/22.

During the same period wait times for patients in the system ballooned, with some waiting years to access care.

At the same time practices at GIDS were coming under increasing scrutiny after former patients and whistleblowing staff claimed youngsters were being rushed onto medication like puberty blockers despite concerns over their use.

This included Keira Bell who previously took the clinic to the High Court, claiming she had not been challenged enough, before being prescribed puberty blockers at just 16.

These concerns, which have been largely validated by the Cass review, surrounded a lack of evidence regarding the safety of their use in patients and uncertainty about their long-term impact on patients' health.