Detailed response to The Cass Review's Final Report

Statement / comment
22 April 2024

The Royal College of Psychiatrists has published its more detailed response to the independent review of gender identity services for children and young people, commissioned by NHS England and chaired by Dr Hilary Cass OBE. 

The College as well as many psychiatrists and other professionals have engaged directly in this work. The final report reflects this engagement along with demonstrable and welcome input from those with lived experience and their families. 

Below is our more detailed response to The Cass Review’s Final Report:

Dr Lade Smith CBE, President of the Royal College of Psychiatrists, said: 

“We welcome the final report of The Cass Review and the involvement throughout of those with lived experience, their families and healthcare professionals in its development. It is a comprehensive and evidence-based assessment that needs to be acted upon with a fully resourced implementation plan. 

“The review directly impacts on the healthcare needs of a vulnerable group of children and young people who are questioning their gender identity or experiencing gender dysphoria, and have had difficulty getting the support they need when accessing services in England. Many young people may be left wondering what services they will have in future and when the recommendations will be acted on. It is crucial that in the future development of services they have access to a comprehensive biopsychosocial approach tailored to meet their individual needs, including the development of an individualised care plan that takes account of their wishes and preferences.  

“The best interests of children and young people seeking support must be at the heart of services provided. Clinicians should not allow their own personal views to influence the care they provide in line with the standards set out by the General Medical Council (GMC) in Good Medical Practice

“The Cass Review is guided and driven by: the best interests of the child and young person presenting for support,  evidence in terms of what exists and highlighting gaps where it does not, and  the views of those with lived experience as well as other key stakeholders, including parents and healthcare professionals. 

“The report highlights concern around the evidence base for the interventions that have been used in providing gender identity services in England. Children and young people in other spheres of healthcare routinely receive evidence-based treatment and rightly so. This should be the same for young people and children seeking support for their gender identity.  

“We strongly agree with the recommendations which seek to ensure that there is proper evaluation of the risk and benefits of any intervention, and that transparent, high-quality data and research-led approaches are used.  

“The report has highlighted that routine data collection on longer term outcomes was not available to the review team. This should never be the case. We call upon all relevant services to support the full programme of research recommended in the report. This will ensure researchers and service evaluators have access to comprehensive data on the characteristics, interventions, experiences and outcomes of every young person presenting to NHS gender services. 

“In all aspects of healthcare, we expect a holistic and person-centred approach to be adopted to understand the full extent of a patient's needs. As the report highlights, that has not necessarily been happening consistently, including in areas of assessment of risk and safeguarding. We know that many of these young people are at risk of developing mental illness and have neurodevelopmental disorders. It is crucial that these are considered and treated as part of a child-centred approach.  

“We endorse the paediatric-led model that the report is broadly recommending. The approach must be child-centred, identifying the specific factors in each patient seen, leading to an individual formulation of treatment and support needs. For example, the pathway for a 15-year-old presenting with gender identity issues and associated autism and depression should look different to someone of the same age, without those co-existing conditions.  

“To deliver this tailored approach we support the establishment of a National Provider Collaborative to ensure services work in line with shared standards and operating procedures, developing best evidence-informed protocols for assessment, consent, safeguarding and treatment. This work should be informed by the expertise of the trans community, as well as that of clinicians and researchers. Good governance structures are vital as are regulatory systems. 

“The recognition of the complex interplay of biological, psychological, and social factors in gender identity development is particularly welcomed, as it aligns with the biopsychosocial model central to psychiatric practice. 

“The approach recommended by The Cass Review will need to be adapted and reviewed over time as we draw upon evidence from the planned research and real-world outcomes from clinical data. This is essential to expanding the evidence base for providing care for this cohort of patients. However, clinicians must maintain the core principles of individual and tailored care highlighted in the report. This should not be a “one-size fits all” approach. 

“We also welcome the reference of the need for follow up services for those aged between 17 and 25. We know that transition between child and adult services can be difficult in healthcare generally, and given the specific issues this report has identified, it is crucial that there is not a cliff edge for this group in terms of accessing the services that best meet their needs. 

“We must, however, face the reality of the mismatch between demand and availability that exists in mental health services in England. These challenges, particularly in Child and Adolescent Mental Health Services (CAMHS) are highlighted in the report as being a risk to the success of its recommendations, if not addressed. It is in this context we note the Review’s recommendation that a child psychiatrist may well be the nominated medical practitioner who takes overall clinical responsibility for patient safety within a service. 

“Despite the welcome prioritisation of funding for the CAMHS services by NHS England, the increasing numbers requiring support means that to implement the model set out in the report, we need an urgent increase in resources, as well as a programme of work aimed at expanding the workforce in this area. Without this action we run the risk of continuing to let young people down who are questioning their gender identity or experiencing gender dysphoria. 

“Workforce capacity is particularly complex for this group of patients. Beyond the general shortage of psychiatrists across mental health services, there is a shortage of expert clinicians to provide these services. 

“An additional factor needs to be acknowledged and addressed. This is the toxicity of the debate, often with individual clinicians being subject to abuse and criticism. If we are to address this and build the capacity needed, everyone from government level down need to approach this area in a respectful and considered way so that people feel comfortable working in this area. 

“As part of addressing this, we will work proactively to support trans members of the College, as well as providing education and training for psychiatrists who are or will be working in these services. We will also provide access to the full range of College support including the Psychiatrists’ Support Service.  

“We also support the recommendation in the Report that all relevant Medical Royal Colleges and professional bodies should develop a shared skills and competency framework relevant to all clinical and social care staff working in this area at different levels within the system. 

“The College will establish a working group of experts and stakeholders in this area to support the development of better care systems. The group will include a range of specialist staff from different disciplines, along with patient and carer representatives being involved in the design of care pathways. As always, the approach will be evidence based and not ideologically driven.  

“In the wake of the publication of the report, and the closure of the GIDS service, there are understandable concerns and significant confusion about meeting the needs of this patient group. Addressing this must be an urgent priority for clinicians and services, as there is no doubt that this group of young people face significant distress, high levels of concurrent health needs, a prospect of poorer care and face long waiting times, often without support. 

“It is also important to recognise that trans members of the College and the wider trans community have raised concerns about the negative impact of the report. This includes how the review's conclusions on the evidence base of different interventions and the need to wait for further research, in combination with the knowledge that existing services are unable to meet demand, will leave gender questioning children and young people feeling unsupported and unseen.

"There is a strong view that the report makes assumptions in areas such as social transition and possible explanations for the increase in the numbers of people who have a trans or gender diverse identity, which contrasts with the more decisive statements about treatment approaches. During implementation, these views should be taken into account to ensure every child, young person and their families feel supported by all. This will require individuals with lived experience being directly and comprehensively involved in the ongoing process. 

“While the report presents challenges, it also offers a roadmap toward more effective, compassionate, and evidence-based care for transgender and gender-questioning children and young people. The Royal College of Psychiatrists will collaborate with stakeholders across the spectrum to implement these recommendations and improve outcomes for this underserved population.”