The Independent Review of Gender Identity Services for Children and Young People was commissioned by NHS England and NHS Improvement in the autumn of 2020 and chaired by Dr. Hilary Cass, retired consultant paediatrician and former president of the Royal College of Paediatrics and Child Health. The final report was duly published on 10 April 2024. The main body of this 388-page report runs to 232 pages, including 32 overlapping recommendations, and is supplemented by a glossary, a list of references, and twelve appendices. Its size and repetitive content will ensure that few people will be sufficiently motivated to spare the time to peruse the report in its entirety. It is hence useful to reflect on some of its key conclusions instead.
The rationale for the Cass Review was provided by a recent and rapid increase in referrals of children and young people (CYP) to gender identity services, a phenomenon which is by no means confined to England but has also been observed in many other Western countries. Birth-registered males presenting in childhood with gender incongruence or gender dysphoria have been overtaken in numbers by birth-registered adolescent females displaying same-sex attraction and gender-related distress. Many of these young females also have co-existing mental health issues, including neurodiversity (autistic spectrum disorder; attention deficit hyperactivity disorder), may have been bullied at school, or may have suffered other adverse life experiences, including parental loss or discord, and domestic abuse and violence.
The Review “is not about defining what it means to be trans, nor about undermining validity of trans identities, challenging the right of people to express themselves, or rolling back on people’s rights to healthcare.” Rather, it is about ensuring that CYP with gender-related distress “receive a high standard of care, that meets their needs, is safe, holistic and effective”. This care should be guided by evidence-based care pathways for gender transition in CYP, to be developed in the light of ongoing research, in the controlled setting of Regional Centres for 17-to-25-year olds, which are to be supplemented by appropriate follow-through services.
The Review is not a definitive document, there being insufficient research evidence upon which to base long-term recommendations. There is indeed a diversity of professional opinions about gender transition, a weak evidence base for existing interventions, and a paucity of information on the potential outcomes of treatment, including the numbers of those who choose to detransition. This means that controlled and monitored medical transition in a research setting provides the only reasonable way forward in resolving what remains a contentious issue.
Services for CYP with gender identity issues began in Canada in the mid-1970s and in the Netherlands in 1987. The UK’s first Gender Identity Development Clinic opened at St George’s Hospital in south London in September 1989, before moving to the Tavistock Clinic in north London in 1994. When the Gender Identity Development Service (GIDS) was first established in the UK in 1989, the service saw less than ten children a year. Adoption of the ‘Dutch Protocol’, first published in 1998 by the Amsterdam child and adolescent gender identity clinic, led to the earlier use of puberty blockers, from the age of 12 and even younger, by the GIDS at the Tavistock and Portman NHS Foundation Trust. This unlicensed, “off-label”, treatment was initially undertaken as part of an ‘Early Intervention Study’ from 2011, before becoming routine practice from 2014 onwards. Referrals to GIDS then took off, rising from 40 male and 32 female children in 2010 to 624 males and 1,740 females by 2019. Since then, critical public scrutiny has brought about the closure of the GIDS, as of 31 March 2024.
Gender transition is ideally a two-stage process, allowing young people the opportunity to explore gender identity in a non-pressurised situation, with the option of changing direction before it is far too late. Initial social transitioning involves coming out to family, friends, or within one’s own social circles, as well as support groups and online communities, and is potentially reversible. During this period, changes to one’s name, clothing, and hair may be accompanied by the adoption of different personal pronouns. Subsequent medical transitioning, on the other hand, is often irreversible. This may entail treatment with hormones and gender reassignment surgery (sex change operations) on the genitals and breasts. Hormone therapy begins with puberty blockers (GnRH analogues)- gonadotropin-releasing hormone agonists which block sex hormone release from the pituitary gland, halting puberty and preventing the appearance of sexual sex characteristics (breasts, facial hair, Adam’s apple). Once on puberty blockers, “cross-sex” or “gender affirming” hormones may be administered, which have either masculinising (testosterone) or feminising (oestrogen) effects depending on the chosen trajectory for gender transition. The long-term effects of such treatments on cognitive function, sexuality, fertility, bone density, and mental health are yet to be fully understood.
Gender identity has become a polarising issue in the ongoing ‘Culture Wars’ of the Western world. Biological sex, which is genetically determined, defined by chromosomes and hormones, is assigned at birth, is considered immutable by many people, based upon various moral, socio-cultural, religious, and other ideological concerns. Personal gender choices made later in life, which may contradict biological sex and thereby contravene societal norms, are thus considered both unnatural and immoral.
The Cass Review provides a measured commentary on the way forward, given the many uncertainties that surround gender transition. It criticises the premature medical transition of younger people, which appears to have been ideologically driven rather than evidence based. Inappropriate early gender transition has led to later demands for detransition, as shown by the legal action taken by Keira Bell against the Tavistock Clinic in 2019. Bell regretted taking puberty blockers and male hormones as a teenager and de-transitioned back to her original female biological sex. It seems likely that demands for early gender transition may reflect unresolved mental health issues rather than a genuine commitment to a trans identity. The Review draws attention to safeguarding issues that resulted from lack of proper oversight and follow-up of medical transition procedures embarked upon by the GIDS. It seems appropriate to delay transition procedures to a later time, beyond at least the age of 18, recognising that not all CYP with gender-related distress will progress to an enduring trans identity.
The Cass Review was not meant to cast aspersion on trans identities, which have been around for many centuries and in many cultures around the world. The report has nonetheless been seized upon by the many opponents of the wider trans community, who particularly condemn the influence of trans activist groups such as Stonewall and Mermaids. Consistently anti-trans views can be discerned within elements of the right-wing media, bolstered by contributions from religious leaders, conservative political commentators, academics, celebrities, and gender-critical feminists, including so-called TERFs (Trans-Exclusionary Radical Feminists). Radical feminists seek to defend women-only spaces, such as public toilets, changing rooms, hostel dormitories, student accommodation, hospital wards, school facilities, domestic violence refuges, and female prisons from trans women, who are identified as predatory men falsely claiming to be women. Women are thus defined anatomically by their possession of a cervix and uterus and physiologically by the occurrence of menstruation, and any person labelled a “woman” cannot also possess a penis. A recent article by Julie Birchill in the Spectator magazine (13 April 2024) identifies the “trans-lobby” as mostly composed of white middle-class men, while applauding J.K. Rowling’s own “transition” from a “prissy modern lefty” to “a practitioner of real, old fashioned communitarianism.”
At times, it is hard to understand the intensity of the hatred directed towards such a small number of people, which periodically declares itself in such tragedies as the murder of 16-year-old Brianna Ghey by two transphobic young people in February 2023. In the 2021 census, only 48,000 (0.10 per cent) people in the UK identified as a trans woman, and a similar number as a trans man. As far as we can tell, the large majority of these trans people appear to be law-abiding citizens who seek to live their lives out of the spotlight, free from persecution. It must also be noted that gender transition in adulthood remains outside the scope of the Cass Review, the conclusions from which thus cannot be used to condemn the wider trans community. Also, given the parlous state of the NHS, how many of the 32 recommendations of the Cass Review eventually come to fruition remains a matter for conjecture.
Ashis Banerjee