Society / April 19, 2024

What the Cass Review Means for Trans Kids in Britain—and Beyond

A new review of gender-affirming healthcare in England could change the way gender-questioning children and young everywhere people receive care.

Natasha Hakimi Zapata
Dr. Hilary Cass in London
Dr. Hilary Cass speaking about the publication of the Independent Review of Gender Identity Services for Children and Young People in London on April 9. (Yui Mok / PA Images via Getty Images)

London—“Gender-questioning kids have been ‘let down’” by the United Kingdom’s National Health Service. That is the conclusion that Dr. Hilary Cass, the former president of the UK’s Royal College of Paediatrics and Child Health, has come to after more than three years carrying out an independent review, published on April 10, into the Tavistock and Portman NHS mental health trust’s gender identity development services (GIDS).

GIDS was at the center of Bell v. Tavistock, a high-profile case brought against the health service in 2019 by Keira Bell. At age 20, four years after beginning her medical transition, Bell became one of the less than 1 percent of people estimated to have “detransitioned” in Britain in recent years—and argued in court that she should have been challenged more by GIDS prior to treatment. The UK’s High Court originally found in favor of Bell, but the case was overturned in 2020 in the Court of Appeal in a ruling that established that it was up to clinicians to “exercise their judgement” when consent was given. Then, in 2020, after a number of healthcare professionals and the Children’s Commissioner for England voiced concerns “related to clinical practice, safeguarding procedures, and assessments of patients’ ability to consent to treatment” at the Tavistock, a Care Quality Commission (CQC) report found GIDS services to be “inadequate.”

Bell’s case and the CQC report increased scrutiny of GIDS, and ultimately led to NHS England commissioning the Independent Review of Gender Identity Services for Children and Young People, which became known as the Cass Review, beginning in 2020. Stating that her goal was to ensure that children and young adults with gender dysphoria receive the best possible care, Cass set out to review the cases of about 9,000 children and young adults who’d received care at GIDS between 2009 and 2020. After “the necessary cooperation was not forthcoming” from several NHS adult gender services the pediatrician attempted to engage in order to obtain follow-up data on former GIDS patients, the review was able to audit only 3,306 cases.

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Cass’s major findings center on a dearth of rigorous medical research in the field of gender medicine, especially when it comes to the impact of GnRH analogues, known as puberty blockers, and cross-sex hormone therapy (CHT). Calling for more studies to be carried out to determine whether these should be prescribed to minors, Cass concluded there had been an “overmedicalization” of gender-questioning young patients in recent years, despite the lack of evidence she found to support the benefits of endocrinological treatment. Of the patients audited, 27 percent of those who’d had two or more GIDS appointments had been referred to endocrinology to explore a medical transition, and an estimated 20 percent of patients had been prescribed puberty blockers.

Puberty blockers, which many gender-questioning youth see as a way to “buy time to think” before deciding whether or not to undergo cross-sex hormone therapy, were a particular focus of the review due to concerns about their impact on bone health and fertility, as well as questions about whether their effects are reversible. Cass’s advice that the drugs be limited to clinical trials for under 18s is now in effect in the NHS and, following her recommendation, puberty blockers will no longer be permitted to be prescribed in the private healthcare sector either.

According to the pediatrician, another major issue in the UK’s approach to gender-questioning young people is that while gender dysphoria had become the main focus of treatment, other issues were ignored at a time when the country has been faced with record high numbers of children experiencing mental health crises.

“What the Cass Review [shows] is that there are no holistic services to help trans people transition,” says Thomas Willett, a cofounder of the LGBTQ+ advocacy group Equality Amplified.

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Additionally, because the London-based GIDS clinic was, for decades, the only NHS clinic in the UK that offered gender-affirming care, there had been an enormous and very slow-moving waiting list of patients from all over the nation. GIDS was shut down in March and, as Cass recommends, regional clinics will be established throughout the country, though there is concern that in the interim many young people may be left without care.

The review’s reception in the British trans community has been mixed. A number of trans youth have reported feeling “disappointed” and “ignored” by Cass—including many who’d been prescribed puberty blockers and had participated in focus groups for the review. British trans activists and researchers also expressed concern about how some of the pediatrician’s recommendations might be interpreted, and were especially worried about the suggestion that “social transitioning” may need clinical supervision. Several campaigners told The Nation that when it comes to recognizing the ongoing failures of Britain’s skeletal gender-affirming care services, however, the Cass review was welcome.

“It’s actually great to have a report to basically confirm what we’ve all been saying all along and to validate our concerns,” says writer and activist Eva Echo, calling trans healthcare in the NHS “beyond broken.”

Several years ago, Echo and three other claimants, including two children, took NHS England to the country’s High Court for what they saw as unlawful waiting times unseen in any other part of the health service—even as waiting lists for a number of treatments have grown in recent years. Their case was ultimately unsuccessful, and Echo, along with thousands of other adults and at least 5,000 children, are still waiting for their first NHS appointment for gender-affirming care.

Astronomical waiting times are just one of the failures the Cass Review identifies, highlighting that during these limbo periods, children are not offered any sort of support, including mental health services. This is especially egregious considering the NHS’s own Healthcare Safety Investigation Branch told Reuters in 2022 that the “‘incredibly distressing’ wait for gender care ‘created a significant patient safety risk for young people.’” There have been a number of suicides linked to waiting times, including Alice Litman, a 20-year-old who’d first sought gender-affirming care at age 15, and was still on a waiting list for more than 1,000 days when she died.

The review’s publication also comes as the country grapples with a stark rise in anti-trans hate crimes amid what Cass herself labeled the “exceptional” “toxicity of the debate” on trans youth healthcare. While some, like Kamran Abbasi, editor in chief of the The BMJ (formerly the British Medical Journal), see the Cass Review as “an opportunity to pause, recalibrate, and place evidence-informed care at the heart of gender medicine,” Amnesty International has warned that it is already being “weaponised by people who revel in spreading disinformation and myths about healthcare for trans young people”. The Scottish author J.K. Rowling has already taken a victory lap on Twitter/X. In an election year, the independent review is also being misused by beleaguered Tories who, like the US right, have resorted to stoking culture wars to distract from dire conditions caused by their policy decisions over nearly 15 years.

It’s not just British anti-trans groups that could “weaponize” it, either. American LBGTQ+ activist and civil rights attorney Alejandra Caraballo has been paying close attention to the Cass Review from across the Atlantic, because the legal expert has identified a disturbing trend in recent years.

“Prominent anti-trans cases in Finland, Sweden, and especially the UK have been cited in US courts,” Caraballo told The Nation. It’s only a matter of time, she believes, before the Cass Review is used in American legal cases looking to further restrict trans rights.

Meanwhile, back in the UK, after years of mounting letdowns, the Cass Review has already transformed the country’s approach to gender dysphoria. It remains to be seen however, when it comes to the well-being of trans children and teens, whether those changes will be for better or for worse.

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Natasha Hakimi Zapata

Natasha Hakimi Zapata is an award-winning journalist and university lecturer based in Europe. Her work has been published in The Nation, In These Times, ScheerPost, the Los Angeles Review of Books, and elsewhere.

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