RCPCH responds to publication of the final report from the Cass Review

On Wednesday 10 April 2024, Dr Hilary Cass published the final recommendations in her role as Chair of the independent review, now more often known as ‘The Cass Review’.
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An Independent Review of Gender Identity Services for Children and Young People was commissioned by NHS England and NHS Improvement in Autumn 2020 to make recommendations about the services provided by the NHS to children and young people who are questioning their gender identity or experiencing gender incongruence or dysphoria. 

The final report focuses on the following areas:  

  • The approach taken by Dr Cass and the review team to draw together the final recommendations
  • The history of services for children and young people with gender dysphoria, including changing demographics and referral rate data over time to provide context to the report
  • Understanding the current cohort of children and young people who are seeking NHS support for gender dysphoria, their needs, and any key drivers to the increase in referrals
  • Clinical approaches and clinical management of gender dysphoria and gender related distress, including the purpose, benefits, and outcomes of clinical interventions in the pathway. This includes the use of hormones and how to support more complex presentations
  • The service delivery model, workforce requirements, pathways of care into the specialist service, further development of the evidence base and how to embed continuous clinical improvement and research into the new service.

You can read the final Cass Review recommendations.
RCPCH will now take the time to review the recommendations made by Dr Cass in full, consider our role to play and identify the needs of our members in order to support the provision of high quality, safe, timely and effective care, with the following principles in mind:

  • Children and young people with gender incongruence or dysphoria must receive the same standards of clinical care, assessment and treatment as every other child or young person accessing health services. As with any other healthcare service, children should be given the opportunity to express what matters to them, and that this is taken into account by healthcare practitioners. This includes the use of pronouns and gender identifiers in line with the child’s wishes, as set out in the NICE Guideline on Babies, children and young people’s experiences of care [1.2.1]. Read more on what LGBTQ+ young people have told us about this.
  • The NHS must deliver a quality health service for this group of patients. As we would expect with any other child health service, this should be timely, high-quality, safe, equitable and effective, and consider each child’s mental and physical health needs in parity. It is important to consider that this group of children and young people has been waiting a long time to access specialist care, and as a result their health needs may be more complex. 
  • With the publication of this review on gender identity services, there is a wider opportunity for the NHS to consider how well health services as a whole are meeting the needs of adolescents, and whether services are working in a joined-up, equitable and timely way for this age group. We encourage the NHS to identify and use opportunities that may come through the implementation of this review to consider the needs of all young people.
  • RCPCH members already see children who are gender questioning or experiencing gender dysphoria in a whole range of healthcare settings. Data collected by Dr Cass in 2021 has shown us that the confidence of paediatricians and GPs to support this group fell below the sample in comparison to other healthcare professionals. This highlights that there is a need for NHSE, with input from relevant specialties, to develop and deliver training to paediatricians and GPs to build confidence and support them in utilising their existing skills to provide timely, safe, effective, and high-quality care for this group, while undertaking their role in the new model of care and providing support for children and young people who face long waiting times to access specialist services. 
  • The lack of data and research in this healthcare space is a significant barrier to effective commissioning, and therefore to improving outcomes for children and young people who are gender questioning or experiencing gender dysphoria. The health system must get better at capturing data on children's health and care needs, their interactions with health services, and their outcomes over time, in order to deliver effective and evidence-based care. This is particularly true for under-researched areas of healthcare provision, such as pathways of care for children who are experiencing gender dysphoria. Healthcare commissioners, providers and researchers have a duty to future generations to improve the understanding of all of the interventions available to support those who are gender questioning or experiencing gender dysphoria, in order to improve the efficacy and safety of the care that paediatricians provide to this group. 

Responding to the report, Professor Steve Turner, RCPCH President, said: 

The final report published by Dr Hilary Cass today is the accumulation of three years of stakeholder engagement, evidence reviews and service assessment. It is a massive undertaking, and we thank the review team for this important work. We will closely consider the report’s recommendations.  

For some time now, rising demand for Gender Identity Services across the UK has led to significant waiting times for children with gender-related distress, leaving these young people particularly underserved and vulnerable. It’s obvious that more resources are needed to address the holistic health needs of this young cohort. 

As a College, we are clear that the needs of children and young people should be front and centre of how services are designed to care for them.  We remain committed to continuing our work to advocate for this patient group and the workforce which supports them. Regardless of where children and young people seek help or what their specific health needs are, we must all work together to ensure they receive the highest quality care, as quickly as possible. 

It is essential that NHS England now provides the necessary additional guidance and support needed for paediatricians and the wider child health team to undertake their important role of caring for children who are gender questioning or experiencing gender dysphoria. We will continue to engage with NHS England, our members, and children and young people on this matter as the new services develop. 

You can read more about our work on gender identity services and advocacy for children and young people.