Landmark English review urges ‘extreme caution’ on youth gender identity healthcare

Healthcare for children and young people grappling with gender identity issues should be “holistic” and providers should exercise “extreme caution” around prescribing hormone treatments to older teens, according to an eagerly-awaited independent English review, published late on Tuesday, April 9.

The four-year probe of gender identity services for the cohort, led by retired pediatrician Hilary Cass, makes dozens of other recommendations, ranging from more research to reform of the referrals system.

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 review its policy on giving children masculinising or feminising hormones from aged 16, urging “extreme caution.” There “should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18,” it said in one of the key recommendations.

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.” She noted she had faced criticism for engaging with groups keen on gender affirmation and those wanting a more cautious approach.

‘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 many healthcare professionals are afraid to openly discuss their views, and that bullying behavior “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 estrogen.

Meanwhile, the country’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. Two new regional hubs opened in London and northern England have been seen as an effort to move away from a single-service model.

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”, he said.

‘Careful consideration’

The review said the use of hormones should be part of a research program alongside a puberty blocker trial which is expected to be in place by December. Meanwhile young people aged 17-25 should have a “follow-through” service for care instead of going straight into adult services, it added.

This would “ensure continuity of care and support at a potentially vulnerable stage in their journey,” the report stated. NHS England said it would detail “a full implementation plan” after “careful consideration” of the recommendations.

It added management has written to local leaders to pause first appointment offers at adult gender clinics to young people before their 18^th birthday. Meanwhile, it is “bringing forward its systemic review of adult gender services.”

Prime Minister Rishi Sunak welcomed Cass’ work, “which urges treating these children, who often have complex needs, with great care and compassion.” Agreeing “extreme caution” was needed, he added: “We simply do not know the long-term impacts of medical treatment or social transitioning on them.”

Noting the government had already acted on some of her interim findings, including stopping the routine use of puberty blockers, Sunak vowed to “ensure we take the right steps to protect young people.”

Le Monde with AFP