Cass Review: how should gender-confused children be treated?

10 May 2024

Carys Moseley continues her series giving a Christian perspective on the Cass Review. Read parts 1 and 2.

The most important part of the Cass Review into Gender Identity Services for children is its recommendations on what the new Service Model should look like.

The review was asked to make recommendations on care pathways into local services and specialist gender services. It was also asked to make recommendations on the workforce involved and on the follow-up of patients and research.

How well are Cass’s recommendations likely to serve children’s wellbeing?

Hearing children’s cries for good mental healthcare

Early on, Cass found that children referred to the GIDS still needed a real connection with local services for mental health and social care.

She emphasises that even the children themselves and their families complained of the effect of being referred to GIDS[1]. The exclusive focus on gender meant that their other mental and behavioural problems were not considered alongside their gender distress.

Hearing children’s cries for adequate mental healthcare has been one of the most important aspects of the Cass Review. In the same breath, Cass also re-emphasised the problem with the lack of initial safeguarding assessment at the GIDS.

Clinicians expressed fear of a ban on ‘conversion practices’

Strikingly, despite not opposing a ban on ‘conversion practices’, Cass reveals the problems involved with this policy.

She says that clinicians working with gender-distressed children said they were worried about a law banning conversion practices inhibiting their work. As a result, they had become afraid of accepting referrals of such children[2].

At this point, Cass called for ‘strong safeguards’ in any government legislation on this topic to avert legal challenges to clinicians. She warned that clinicians’ confidence depended upon this. Prime Minister Rishi Sunak was alleged to have scrapped plans for a law around the time that the Cass Review’s final report was published. Perhaps this was not a coincidence, given strong government support for Cass.

Weak evidence base and politicisation harmed recruitment

In line with this concern, Cass went on to issue a further warning. As has already been said, the evidence base for the work of the GIDS was too weak and adequate professional guidance was not to be found. The field itself is highly emotive and therefore stressful, and is politicised to a high degree.

Cass says that this combination of problems has made it more difficult for the new gender hubs to recruit staff.

The proposed new service model

Having run through various options for a new service model, Cass describes the preferred one, which she terms ‘Clinical network plus’.

In this, all patients would receive fundamentally the same treatment at all sites. Consistency for all children goes hand in hand with ensuring they do not just receive attention for gender distress.

Further on, she also says that research and training continues to happen at the local level.

Establishing a National Provider Collaborative

To ensure care standards and access are kept up, Cass wants the regional hubs to form a National Provider Collaborative (NPC)[3].

It would deal with tasks including setting shared standards, updating the assessment framework for patients, developing clear criteria for referring children, a form for discussing complex cases, and providing Continuing Professional Development.

Significantly, Cass wants it to include an ethics forum for looking at children where there is uncertainty, or where there are disagreements about the best interests of the child or over what care is right. She wants this NPC to include both clinicians and outside experts. The important question here will be how would outside experts be selected.

Establishing a Consortium of Professional Bodies

Cass wants NHS England to commission a lead organisation to establish a Consortium of Professional Bodies. This would be responsible for drawing up a framework for the skills and competency of clinicians and social care staff. She emphasises the need for skills in adolescent care.

“An effective approach would be to establish a consortium to include relevant Medical Royal Colleges, special interest groups and other professional bodies, including but not limited to: • Association of Clinical Psychologists • Association of Psychotherapists • Royal College of Speech and Language Therapists • Royal College of Occupational Therapists • British Association of Social Workers.”

There is a major problem here. There is no professional body called the Association of Psychotherapists. There was a British Association of Psychotherapists, but the company was dissolved in 2019. Nevertheless this list is significant for its complete omission of members of the coalition that signed the Memorandum of Understanding (MOU). The MOU Coalition is made up of all the major professional mental health bodies who signed up to the professional ban on conversion therapy/practices.

This suggests that Cass is sidelining the MOU Coalition. In accepting the Cass Review’s final report, the government signals that it agrees with this approach.

UK Council for Psychotherapy supports Cass Review against trans activists

In light of this it is highly significant that the UK Council for Psychotherapy has recently withdrawn from the professional ban on conversion therapy, the MOU. The UKCP disagreed with the updated version of the MOU which included children. In response, a group called Therapists Against Conversion Therapy and Transphobia started a petition demanding board members resign. It also called for a vote of no confidence in them. The petition has more than 1,500 signatures, which rather tellingly amounts to over a tenth of the UKCP’s membership.

It is not too much to say that the Cass Review has put the credibility of professional mental health bodies on the line.

The need for a single trusted source of information

In line with this shift to less untrustworthy organisations, it is interesting that Cass highlights the need for a ‘single trusted source of information’.

She reveals that children and families expressed concern that the NHS does not provide ‘a single trusted source of information’ on gender dysphoria[4].

I warned about problems with the NHS website back in 2020. Cass wants the National Provider Collaborative to produce this source. She also wants the information to go out not only to children referred to the new gender hubs, but also to schools and social care services.

This requires more comment than Cass has provided. In my previous article for this current series, I said that the Cass Review did not investigate the influence of transgender activism in schools in relation to the rise in GIDS referrals. Does Cass have unacknowledged information about schools? Or is her recommendation merely made to pre-empt the likes of Mermaids from attempting to undo the implementation of her review by influencing schools?

Cass does not oppose childhood ‘transition’

Despite the important steps forward made by the Cass Review, we should not idealise it nor stay silent when it fails morally. Cass does not wholly oppose the practice of allowing children to live as if they were members of the opposite sex before puberty.

Her comments on this regrettably represent a stunning lack of insight.

“In reviewing cases put forward for puberty blockers, the MPRG noted that children who had socially transitioned early and completely were likely to approach puberty in a fearful and anxious state because of living ‘in stealth’.”

Surely the reality is that these children are fearful of puberty because they already were long before reaching it.

Shockingly, Cass says there should be no lower age limit for children’s ‘options’ (for transition) remaining open:

“Helping parents and families to ensure that options remain open and flexible for the child, whilst ensuring that the child is able to function well in school and socially is an important aspect of care provision and there should be no lower age limit for accessing such help and support.”

This will sound odd given that Cass has recommended prohibiting the administration of puberty blockers except in a research programme evaluating their outcomes. In her assessment of how the GIDS has treated children, she found that the list of reasons given for puberty blockers had been extended over time. She also found that they do not buy time to think through gender distress, nor is there evidence to prove that they reduce gender dysphoria.

However, it is crucial to note that Cass never recommends a total prohibition on puberty blockers. In her final section on the proposed Service Model, she even says children may benefit from puberty blockers.

“Importantly some children within this group who remain gender incongruent into puberty may benefit from puberty blockers and will be able to enter the specialist component of the service and access the puberty blocker trial in a timely way, if already under the supervision of the regional network.”

So there we have it: the ‘research trial’ on puberty blockers is intended for children who were already treated as members of the opposite sex from a very young age.

This frankly shows an attitude of not pursuing the causes of childhood gender dysphoria; specifically, not wanting to upset parents who deliberately try to change their own children. Nobody should be surprised by this inconsistency; it was visible two years ago.

More help needed for detransitioners

It is nevertheless good that the Cass Review tends to end on a more positive note. Cass seems serious about the need for more and better help for detransitioners.

“NHS England should ensure there is provision for people considering detransition, recognising that they may not wish to re-engage with the services they were previously under.”

Cass wants there to be a consultation on a possible new pathway for detransitioners, engaging detransitioners themselves:

“Consideration should be given to whether existing service specifications need to be adapted to specifically provide for detransition pathways, or whether this should be a separately commissioned service. This should be in consultation with people who have been through detransition.”

This is good news. Clearly, there needs to be a distinct pathway; as Cass hints, detransitioners do not trust the staff of gender identity clinics who humoured their fantasies in the first place. There are too many that are unethical and deeply incompetent quacks.

She thinks the NHS should help detransitioners:

“NHS gender services should support all those presenting with gender incongruence and dysphoria, whether that be to transition, detransition or retransition. Those who choose to detransition should be carefully monitored in a supportive setting, particularly when coming off hormone treatments.”

It is to be expected that Cass would prioritise the effect of hormone treatments more than psychological help, but this exemplifies the weakness of the Cass Review as a whole.

Nevertheless, it is good to know that Cass wants the professionals to listen to and learn from detransitioners themselves. Such professionals have been coming forward in recent years, for example psychotherapist James Caspian. Having supported adults who wanted to undergo gender reassignment for many years, Caspian started to find that such patients were getting younger and that more were regretting their choices. His proposal to research the experiences of such regretters was barred by Bath Spa University for fear of offending transgender advocates.

Cass also wants their experiences to contribute to better understanding of children’s needs.

“It is also important that services understand and learn from those who choose to detransition as their experience can be used to inform understanding of what services are required earlier in the pathway. There is also the need for more research to understand what factors contribute to the decision to detransition.”

This brief but focused call for more and better work with detransitioners is very welcome.

Let’s hope it will bear good fruit here in the UK and influence other countries.

In light of this, I shall consider in my next article how major public figures have responded to the Cass Review, and how this is shaping beliefs in society around our human nature.

Read part 4.

[1] Cass Review 17.2

[2] Cass Review 17.21

[3] Cass Review 18:20

[4] Cass Review 18:50

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