Next month marks a year since paediatrician Dr Hilary Cass published her landmark review on gender identity services for children and young people (aged under 18).
After assessing all available research about treatment approaches for gender dysphoria, her review team found it to be an area of “remarkably weak evidence”.
The government-commissioned review found gender incongruence arose “from a combination of biological, psychological, social and cultural factors” and that first-line management should be psychological and psychosocial therapy, rather than medical intervention.
In the run up to that first year anniversary, The Clinical Advisory Group on Sex and Gender (CAN-SG) hosted a panel discussion on 6 March to discuss progress in delivering the report’s 32 recommendations.
Hannah Barnes
First to speak was Hannah Barnes, an award-winning journalist and author of Sunday Times best seller Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children. She charted the history of the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust, and key events that led to its closure in March 2024.
Barnes said there had been “multiple missed opportunities” to challenge its practices.
Following its launch in 1989, the GIDS service operated at small scale for two decades but in 2009 it became a national NHS provider and, between 2010 and 2015, GIDS saw a more than 10-fold increase in referrals, said Barnes. Not only that, but there was also a significant change in the sex ratio of those being referred too; by 2015, two-thirds of referrals were for girls whereas, historically, the majority of referrals had been for boys.
GIDS also transformed its approach to the treatment of children with gender dysphoria. It became an assessment service deciding whether children should have puberty blocking medication. By mid-2014, giving them to younger children without follow-up had become routine clinical practice and continued even after 2016, when it was clear there had not been any change in psychological wellbeing after at least a year.
The service even expanded the use of hormone blockers beyond the original inclusion criteria. “GIDS took an already extremely weak evidence base and applied it to a completely different cohort. They were open about it. They told parliament about it. They had the decision approved by NHS England, and no one said anything.”
By the time GIDS reported the results of its puberty blocker trial – in 2021 – more than 1,500 children had been prescribed puberty blockers.
Barnes said three factors combined to bring about the closure of the GIDS service. These were a judicial review, brought by former patient Keira Bell in December 2020, which exposed how GIDS had failed to collect any meaningful data on patients; a damning CQC inspection in 2020; and judgement by the (NICE) Institute for Health and Care Excellence that the quality of evidence for the use of synthetic hormones in the treatment of gender dysphoria was “very low.”
Barnes believes that without better vigilance, there is a risk that clinicians will repeat the mistakes of the past. “There have been no major consequences for anyone involved,” she concluded. “The clinical lead for GIDS who prescribed those blockers based on poor assessments and continued to do so when data showed them to be of little benefit, was invited to Parliament just a few weeks ago to give his expert opinion on how to conduct a medical trial. What were these politicians thinking? And with the news that the planned puberty blocker trial will only follow up children for two years? I do fear that we have learned little and are at risk of repeating some of these mistakes again.”
Professor Sallie Baxendale
One clear lesson from the past is that expert consensus is often wrong, said Professor Sallie Baxendale, Professor of Clinical Neuropsychology at the UCL, Queen Square, Institute of Neurology in London, and the next speaker.
With a particular interest in evidence based practice she explained the importance of being guided by evidence. That’s why researchers now use an ‘evidence pyramid’ to classify evidence according to its quality. On the bottom two rungs are case reports, expert opinion and review articles but at the pinnacle is the gold standard of evidence meta analyses.
Having assessed the strength of the evidence of the Cass Review, Professor Baxendale said: “The Cass review sits right at the top of the evidence pyramid.” Integrating literature reviews, research, qualitative reviews, and surveys, she said: “It pulls together absolutely everything, even better than a single meta-analysis.”
She said some responses to the Cass Review were posted on social media within 28 seconds it being published – proof that responders had not engaged with the evidence. Negative responses ranged from insults, ad hominem attacks and rebuttals with made-up facts. More challenging were opinions by clinicians in peer reviewed journals, which held more credibility.
But, after reviewing all criticisms, she said none had successfully challenged Cass’s central argument – that the published studies on the treatment of gender dysphoria are of poor quality, meaning there is not a reliable evidence base upon which to make clinical decisions.
“Nobody, not from social media, right the way up to the published reviews in peer reviewed journals, has refuted that central point.”
Any clinicians confronted with similar criticisms should assess any new information against the central argument.
“This is the key thing that you need to ask: ‘is the person presenting firm evidence based on high quality studies that allow the clinicians to make a decision?’ And is the criticism that you are reading actually counteracting that and saying ‘look, here is that evidence’? If it’s not, then it’s not a valid criticism.
“And having looked, I cannot find any valid criticism of Cass.”
Two former employees at Tavistock GIDS whose testimony featured in Hannah Barnes’ reporting also spoke.
Anastassis Spiliadis
Anastassis Spiliadis is a consultant systemic and family psychotherapist with a background in psychology, said Cass had opened the door to a renewed opportunity for psychotherapy in the treatment of gender dysphoria.
He said in around 2009, when GIDS became a national service, psychotherapeutic intervention “was completely abandoned”. He remembered that some of the senior staff did not believe that psychotherapeutic interventions could be successful in alleviating gender related distress and improving psychosocial functioning.
He accepted there was a lack of evidence to counter that view, but he said there was plenty of evidence from clinical practice that some psychotherapeutic approaches worked in alleviating distress, improving psychosocial functioning, and helping young people to thrive.
“This is not rocket science,” he said. “We do have conditions and clinical issues in adolescence where we know that psychotherapeutic approaches, which are evidence informed, can have a really good success rate. We know that different therapeutic approaches have different evidence.
“Yes, we don’t have any evidence of what really works with gender but that is not because nothing works – it’s because no one has really looked into this.”
He said there was strong evidence that psychotherapy works with adolescents with embodied distress; for young people with eating disorders, and for young people suffering with Body Dysmorphic Disorder.
Spiliadis, who has been involved in developing training materials for the new NHS children and young people’s gender services, acknowledged fears that any attempts to support young people psychotherapeutically could be labelled as conversion therapy. But he advised that the relationship between the therapist and the patient was paramount. “In most of the cases where therapy has failed to be helpful with a gender related distressed youth, it’s because they have been told that any psychotherapy is a form of conversion therapy. So we really need to take into account what happens outside the therapy room and how this informs young people and families presenting for support.
“We really need to be clear in what we’re offering young people and families, and they need to know what is an offer in order for them to be able to consent.”
Dr Anna Hutchinson
In the wake of the Cass review but ahead of the roll out of the new gender hubs and any new models of working, what should clinicians be offering young people who are seeking help right now? This question was the focus of the last speaker, Dr Anna Hutchinson, a clinical psychologist and the Clinical Director at The Integrated Psychology Clinic in London.
She said the Cass review was very helpful in guiding their practice in a number of ways.
She encouraged psychotherapists to read the Cass recommendations. “They’re identical to the recommendations that are made for all young people in distress,” she said. “Cass actually recommends a bio-psychosocial approach, as is recommended for all young people with distress.”
Psychotherapists had the tools to help young people with gender dysphoria, but often fear of getting it wrong got in the way, she said. “The debates about who these young people are and how best to help them, are toxic and they’re hostile. People are scared of getting it wrong for the kids, but they’re scared of getting it wrong and being punished socially as well. Culture is getting in the way, not our ability to help.”
To counter that, she said therapists needed to increase their cultural competence – the ability to understand and effectively engage with people from a diverse range of backgrounds. “The one way to feel less scared is to learn more,” she said. “As psychotherapists, we should position ourselves above the debates and be able to move them. It’s difficult in this arena, but at the very least, we need to own a position we’re working with and be able to explain it to the young people so that they can consent to work with us.
“It’s also our duty to address misinformation, and I think that’s absolutely the case, because we have a duty of candour when working with our young people. So we need to know the whole story and all the debates from every angle.”
Dr Hutchinson, who recently co-led the induction training for the new NHS Children and Young People Gender Hubs in collaboration, added: “We can learn from the young people based on the stories we’re hearing in the clinic rooms – they may be right that some things still need to be queered, I’m talking about sex stereotypes and what it means to live as a same sex attracted person in our society.
“But Cass reminds us that there are some things that we shouldn’t queer. And I don’t think we should be queering safeguarding, and we certainly shouldn’t be queering evidence based medicine, so therapy with gender questioning children is both possible and necessary, and Cass has helped us with that.”
Discussion
The audience had many questions for the panel. Moderating the session, Sonia Sodha, chief leader writer and a columnist at the Observer, kicked it off by asking how would it ever be ethical to put a young person on a life altering medical pathway, as part of a clinical trial, given that there was no way to predict which gender questioning children would have lasting trans identities? How would you decide which children to give hormones to?
“I wouldn’t make that decision,” said Dr Hutchinson. “I’m quite clear that I wouldn’t ever refer anyone for a medical pathway at the moment, because the evidence base isn’t there. The Cass Review says that there’s no predictive validity to the diagnosis, so even if you’ve got the diagnosis, we just don’t know either way. And to me, that feels like a gamble…a gamble I’m not prepared to take.”
“It’s a really thorny issue,” agreed Spilladis. “I’m really curious to see what the inclusion and exclusion criteria will be, I think it’s a really difficult task, but I hope that we will have more visibility over the inclusion and exclusion criteria. I wouldn’t want to be part of that, because I think it’s a really, really tough call.”
One forensic psychologist in the audience told the panel that professionals in her network were backing off from dealing with these children who badly needed their help. Medical psychologists were refusing to take on cases involving gender distressed children, viewing them as “far too risky” and local authority social workers had told her: “We can’t really question a child’s gender identity, can we? It’s just not the done thing.”
She asked how it was possible to implement Cass in such a workplace.
“People have to be a bit braver,” responded Dr Hutchinson. “And I think Cass has allowed people to be a bit braver…One of our jobs as one of our duties as professionals registered by the HCPC is that you have to be aware of your own beliefs and biases. And we really need to call people out in as kind a way as possible.”
Summing up the progress since the publication of the Cass Review, Barnes said the same people who worked in gender service commissioning at the NHS prior to the Cass Review, were still working on it – something she described as “worrying”. But she said it was also important to look at what Cass had achieved already. “We have really cross party consensus in this country politically – look across the Atlantic, we don’t have that political polarisation, thank God. There’s obviously still further to go, but it (Cass Review) has shifted the dial.”