NHS ‘to review all transgender treatment’ after landmark report calls for ‘more cautious approach’ to transitioning

10 April 2024, 00:20 | Updated: 10 April 2024, 00:22

In 2021-2022, over 5,000 referrals to Tavistock were reported by the NHS, compared to just under 250 who were questioning their gender identity ten years earlier
In 2021-2022, over 5,000 referrals to Tavistock were reported by the NHS, compared to just under 250 who were questioning their gender identity ten years earlier. Picture: Alamy
Kieran Kelly

By Kieran Kelly

The NHS is expected to review all transgender treatment after a landmark report concluded that the pillars of gender medicine are "built on shaky foundations".

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Dr Hilary Cass, who wrote the report, said healthcare for people questioning their gender "needs to be improved across the board" but said that there is a distinction between having a trans identity and medically transitioning.

Dr Cass also warned that more care should be taken before anyone under the age of 25 is allowed to transition.

The long-awaited report recommended that under 18s are not prescribed powerful hormone drugs and that many children who want to change their gender end up regretting it.

Many of these children have experienced trauma, neglect and abuse, the report added.

Dr Cass also warned that parents and families are being put under pressure in transitioning debates as they do not want to be labelled transphobic.

“The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress,” she wrote.

The NHS will now review all transgender treatment it is offered, including to both children and adults, The Telegraph reports.

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Treatment for any new patients between the ages of 16 and 17 will also be paused.

Reacting to her findings, Rishi Sunak said: “We simply do not know the long-term impacts of medical treatment or social transitioning on them, and we should therefore exercise extreme caution.”

Rishi Sunak
Rishi Sunak. Picture: Getty

Dr Cass, who chaired the Independent Review of Gender Identity Services for children and young people, said that "many people with gender diverse identities don't want to go down a medical pathway" but will still be in need of support.

Research by the University of York was commissioned to inform the review's final report, including on social transitioning and current evidence around medical interventions.

A review of 50 studies into puberty blockers concluded that there is a "lack of high-quality research" assessing their use in adolescents experiencing gender dysphoria or incongruence and that "no conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development".

It also notes: "Bone health and height may be compromised during treatment."

Dr Cass said while the rationale for puberty blockers remains unclear, "the clearest indication" is they can help birth-registered males to "pass" - look less male - in adult life "by preventing the irreversible changes of male puberty".

Her report added that it had heard that widespread claims puberty blockers reduce the risk of death by suicide "may place pressure on families to obtain private treatment" and that some GPs had been put under pressure "to continue prescribing such treatments on the basis that failing to do so will put young people at risk of suicide".

But the University of York systematic review "found no evidence" they improve dysphoria, and "very limited evidence for positive mental health outcomes".

Another review of 53 studies looking at hormone treatments - masculinising and feminising hormones testosterone and oestrogen - found a "lack of high-quality research" assessing their use in adolescents.

While it found there is moderate-quality evidence suggesting mental health may be improved during treatment, researchers said "robust study is still required".

On the suggestion that hormone treatment reduces risk of death by suicide in children seeking gender care, the evidence found "did not support this conclusion", the review said.

Most of the 23 guidelines - comprising international, regional and national - for managing children with gender dysphoria or incongruence "lacks an independent and evidence-based approach and information about how recommendations were developed".

They warned that this "should be considered" when such guidelines are used to "inform service development and clinical practice".

Writing in the BMJ, Dr Cass said: "The findings of the series of systematic reviews and guideline appraisals are disappointing.

"They suggest that the majority of clinical guidelines have not followed the international standards for guideline development."

She said the World Professional Association of Transgender Healthcare (WPATH) had been "highly influential in directing international practice, although its guidelines were found by the University of York's appraisal to lack developmental rigour and transparency".

In the foreword to her report, Dr Cass said while doctors tend to be cautious in implementing new findings "quite the reverse happened in the field of gender care for children".

She said a single Dutch study, "suggesting puberty blockers may improve psychological wellbeing for a narrowly defined group of children with gender incongruence", had formed the basis for their use to "spread at pace to other countries".

Subsequently, there was a "greater readiness to start masculinising/feminising hormones in mid-teens".

She added: "Some practitioners abandoned normal clinical approaches to holistic assessment, which has meant that this group of young people have been exceptionalised compared to other young people with similarly complex presentations.

They deserve very much better."

Dr Cass said her recommendation for an expanded service "grounded in paediatric services and delivered in a consistent way" should be able to "evolve and adapt" as new research emerges.

She has recommended care must be "much more holistic" and consider a child "as a whole person and not just through the lens of their gender identity.

The overall review noted a higher proportion of birth-registered females presenting to gender services in adolescence, and Dr Cass said there is a lack of follow-up data on this group "who frequently have a range of co-occurring conditions including adverse childhood experiences, autism, and a range of mental health challenges".

She said: "Filling this knowledge gap would be of great help to the young people wanting to make informed choices about their treatment."

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