Landmark review urges caution on English youth gender healthcare

The report urges the NHS to exercise "extreme caution" when prescribing masculinising or feminising hormones to children aged 16 and above.

Healthcare providers for children and young people grappling with gender identity issues should exercise “extreme caution” around prescribing hormone treatments, an eagerly-awaited independent English review said on Wednesday.

The four-year probe of child and youth gender identity services, led by retired paediatrician Hilary Cass, makes dozens of recommendations ranging from more research to reform of the referrals system.

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It was commissioned in 2020 by England’s state-run National Health Service (NHS), following a rise in the number of children and young people questioning their gender and seeking healthcare support.

Running to almost 400 pages, the report urges the NHS to exercise “extreme caution” when prescribing masculinising or feminising hormones to children aged 16 and above.

There “should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18,” it said.

Concerns have grown around the introduction of medical interventions, such as puberty blockers, amid a lack of evidence on their use and long-term impacts.

The issue has become contentious in the UK, as in other countries, with Cass calling the “toxicity” of the debate “exceptional”.

– ‘Stormy social discourse’ –

A former Royal College of Paediatrics president, Cass concluded children have been let down by the dearth of evidence on medical interventions, and “caught in the middle of a stormy social discourse”.

She also noted that many healthcare professionals are afraid to openly discuss their views, and that bullying behaviour “must stop”.

Her report comes just weeks after the NHS in England confirmed that puberty blockers would no longer be given to under-16s outside of research trials.

However, 16- and 17-year-olds can still be given hormones in the form of testosterone or oestrogen.

England’s first gender identity development service for children, run by the Tavistock and Portman NHS Trust, closed last month after years of criticism that it was too quick to prescribe puberty blocking treatment.

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Two new regional hubs were opened in London and northern England.

Cass’s recommendations include that services should operate “to the same standards” as other health provision for children and young people, with “a holistic assessment” of those referred.

That would involve screening for neurodevelopmental conditions such as autism, alongside a mental health assessment.

The report 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.

In such cases, it is important “parents are not unconsciously influencing the child’s gender expression”, it said.

– ‘Careful consideration’ –

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

Young people aged 17-25 should have a “follow-through” service for care “at a potentially vulnerable stage in their journey” instead of going straight into adult services, it added.

NHS England said it would detail “a full implementation plan” after “careful consideration” of the recommendations.

It added that management had written to local leaders to pause first appointment offers at adult gender clinics to young people before their 18th birthday.

Doctor and whistleblower David Bell, the former governor of the Tavistock trust, said the report implied that “generations of children and young people have been seriously damaged” by medical intervention.

As a consequence, multiple other problems such as autism, depression, trauma and abuse, had been overlooked.

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“These children suffered from being given the wrong treatment, and also the problems that they did have were not addressed,” Bell told Times Radio.

Prime Minister Rishi Sunak said Cass’s work had shone “a spotlight on the fact that we need to exercise extreme caution when it comes to these issues”.

“We simply do not know the long-term effects,” he told LBC Radio.

Sunak added that the government had already acted on some of Cass’s interim findings, including stopping the routine use of puberty blockers for young people being treated in the NHS.

© Agence France-Presse