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Weak evidence and controversy surrounding medical treatments has taken focus away from the role of gender identity services for children and young people, according to a new independent review.
The report by Dr Hilary Cass, commissioned by NHS England, makes recommendations on how to improve NHS gender identity services. The aim is to ensure that children and young people who are questioning their gender identity or experiencing gender dysphoria receive a high standard of care, that meets their needs, is safe, holistic and effective.
It also set out to understand the reasons for the growth in referrals and the change in case-mix, and to identify the clinical approach and service model that would best serve this population.
In the report, Dr Cass said that exploration of identity is a completely natural process during childhood and adolescence and rarely requires clinical input. However, over the past five – ten years the number of children and young people being referred for NHS support around their gender identity has increased rapidly.
As a result, young people are waiting several years to receive clinical support and during this time they and their families are left to make sense of their individual situations, often dealing with considerable challenges and upheaval.
The report found that there is no simple explanation for the increase in the numbers of predominantly young people and young adults who have a trans or gender diverse identity, but there is broad agreement that it is a result of a complex interplay between biological, psychological and social factors. This balance of factors will be different in each individual.
Role of clinicians in gender services
An appraisal of international guidelines for care and treatment of children and young people with gender incongruence found that that no single guideline could be applied in its entirety to the NHS in England.
In addition, while a considerable amount of research has been published in this field, systematic evidence reviews demonstrated the poor quality of the published studies, meaning there is not a reliable evidence base upon which to make clinical decisions, or for children and their families to make informed choices.
The strengths and weaknesses of the evidence base on the care of children and young people are often misrepresented and overstated, both in scientific publications and social debate.
The report also found for most young people, a medical pathway will not be the best way to manage their gender-related distress. For those young people for whom a medical pathway is clinically indicated, it is not enough to provide this without also addressing wider mental health and/or psychosocially challenging problems.
In addition, clinicians are unable to determine with any certainty which children and young people will go on to have an enduring trans identity.
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Overview of Recommendations
The report recommended that children/ young people referred to NHS gender services must receive a holistic assessment of their needs to inform an individualised care plan. This should include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment.
Standard evidence based psychological and psychopharmacological treatment approaches should be used to support the management of the associated distress from gender incongruence and cooccurring conditions, including support for parents/carers and siblings as appropriate.
Services should also establish a separate pathway for pre-pubertal children and their families. ensuring that they are prioritised for early discussion about how parents can best support their child in a balanced and non-judgemental way. When families/carers are making decisions about social transition of pre-pubertal children, services should ensure that they can be seen as early as possible by a clinical professional with relevant experience.
Other recommendations included:
- Provision for people considering detransition, recognising that they may not wish to re-engage with the services whose care they were previously under.
- A full programme of research should be established to look at the characteristics, interventions and outcomes of every young person presenting to the NHS gender services.
- The puberty blocker trial previously announced by NHS England should be part of a programme of research which also evaluates outcomes of psychosocial interventions and masculinising/ feminising hormones.
- The option to provide masculinising/feminising hormones from age 16 is available, but the Review recommends extreme caution. There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18. Every case considered for medical treatment should be discussed at a national Multi- Disciplinary Team (MDT).
- Implications of private healthcare on any future requests to the NHS for treatment, monitoring and/or involvement in research, and the dispensing responsibilities of pharmacists of private prescriptions needs to be clearly communicated.
Health and Social Care Secretary Victoria Atkins said: “I am grateful to Dr Hilary Cass for her work in conducting and publishing this critical review of gender identity services for children and young people. These services need to provide the right healthcare, safeguarding and support for children and young people. That means making sure they are based on the very best available evidence and expert clinical opinion.
“The immediate action NHS England has taken to ensure that no child under the age of 18 will be seen by the adult service is welcome. I will be working closely with NHSE to implement further changes as soon as possible to ensure that the support given to children and young people is caring and careful.”
