Cass Review: Major report finds young trans people let down by exceptionally polarised debate as Scottish gender clinic review urged

Young trans people have been “caught in the middle of a stormy social discourse” where there is polarisation and a stifling of debate, according to the findings of a much-anticipated review into gender clinic services in the UK

Transgender children in the UK have been let down by an exceptionally toxic debate on gender issues, according to the findings of the much-anticipated Cass review into gender care.

Dr Hilary Cass said young people had been “caught in the middle of a stormy social discourse” where there is polarisation and a stifling of debate.

But the publication of the report’s findings has sparked fresh calls to review gender clinics in Scotland, as Humza Yousaf’s Government pledged to “take the time to consider the findings”.

Dr Hilary Cass said young people have been “caught in the middle of a stormy social discourse” where there is polarisation and a stifling of debate.

Dr Cass had previously noted in a video explaining her work that people are “afraid to talk openly” and appealed for the public to “put the animosity aside to come to a shared consensus”.

But in a strongly worded foreword to her final report, published on Wednesday, she said the “toxicity of the debate is exceptional”.

She wrote: “I have faced criticism for engaging with groups and individuals who take a social justice approach and advocate for gender affirmation, and have equally been criticised for involving groups and individuals who urge more caution.”

Among the report’s 32 recommendations are a call for gender services to operate “to the same standards” as other health services for children and young people, with “a holistic assessment” of people referred, including screening for neurodevelopmental conditions such as autism, and a mental health assessment.

England’s health service is urged to review its policy on giving children masculinising or feminising hormones from the age of 16, urging “extreme caution”.

Dr Cass, a retired consultant paediatrician, said there “should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18”.

However, as previously reported by The Scotsman, a puberty blockers ban in Scotland is unlikely, according to trans charities, due to the “exceptionally difficult” process patients must go through to acquire gender identity treatment through NHS Scotland.

The waiting times for young people at the Glasgow-based sexual identity clinic Sandyford are in excess of four-and-a-half-years, with clinicians seeing fewer patients per month than are added to the waiting list.

The process for acquiring puberty blockers is slow and laborious, according to the Scottish Trans charity, and increasingly excessive waiting times for trans healthcare mean young trans people are unlikely to acquire them before finishing puberty anyway.

The NHS in England has already called for a halt to the prescription of puberty blockers, which pause the physical changes of puberty such as breast development or facial hair, other than as part of clinical research trials.

Puberty blockers are already prescribed for a significantly larger number of young people experiencing precocious puberty than for trans children, and are still available to the families of trans children willing to pay for private healthcare.

A spokesperson for the Scottish Government said: “We agree with Dr Hilary Cass when she highlights that ‘increasingly toxic, ideological and polarised public debate’ does nothing to serve the young people accessing this care, their families and the NHS staff working hard to care for them.

“Since the Cass Review was commissioned, we’ve closely monitored ongoing findings with Scottish Government officials and NHS Scotland clinicians meeting Dr Cass on a number of occasions to share information about improvement work in Scotland.

“While the Cass Review extends only to services provided by NHS England, we will now take the time to consider the findings of the final report in the context of how such healthcare can be best delivered here in Scotland.”

Robbie de Santos, the director of campaigns and human rights at Stonewall, said many of the Cass Review’s recommendations “could make a positive impact”.

"What is important, above all, is that trans and gender-diverse children get the quality healthcare that they need and deserve,” he said. “The Cass Review can play a vital role in achieving this aim, if its recommendations are implemented properly.

“Many recommendations could make a positive impact – such as expanding provision of healthcare by moving away from a single national service towards a series of regional centres, while recognising that there are many different treatment pathways that trans young people might take.

“But without due care, training or further capacity in the system, others could lead to new barriers that prevent children and young people from accessing the care they need and deserve."

Meanwhile, the Scottish Conservatives have called for a Scottish review into gender clinics.

The deputy leader of the Tories, Meghan Gallacher, said: “Despite repeated calls from medical experts, campaigners and the Scottish Conservatives, the SNP Government refused to undertake a review of gender clinics here in Scotland.

“Instead, the SNP have rushed into significant gender reform, ignoring the wellbeing and health of children seeking medical care for significant issues like gender dysphoria. While there is a lot of information to digest in this report, one of the most damning conclusions is that children have been let down. This is simply unacceptable.

“If the SNP won’t heed the recommendations made by the Cass Review, then they must urgently undertake their own evaluation, so that we can protect the wellbeing of young people, especially children, accessing these services, starting with pausing the use of puberty blockers.”

Dr Cass, the former president of the Royal College of Paediatrics and Child Health, was appointed to lead the Independent Review of Gender Identity Services for children and young people in 2020.

The final report of her independent review of gender identity services for children and young people runs to almost 400 pages and has been close to four years in the making.

The review was commissioned by NHS England in 2020 after a steep rise in the numbers of children and young people presenting to the NHS for help around their gender over the previous decade and amid concerns around the introduction of earlier medical interventions despite a lack of evidence on their use and long-term impacts.