Thursday briefing: Unpicking the landmark Cass report on gender identity services for children

<span>Dr Hilary Cass speaking about the publication of her report.</span><span>Photograph: Yui Mok/PA</span>
Dr Hilary Cass speaking about the publication of her report.Photograph: Yui Mok/PA

Good morning. Almost four years ago, NHS England appointed Dr Hilary Cass to chair an independent review into its services for children and young people questioning their gender identity. Yesterday, her report was finally published – and, to the surprise of nobody who has followed the subject in recent times, it drew vast media attention.

Cass concluded that the NHS was failing thousands of children, and prescribing puberty blockers and cross-sex hormones despite “remarkably weak evidence”. She said that “the toxicity of the debate is exceptional”. And she said that there was an urgent need for the NHS to expand its capacity. “We can’t fix everything overnight,” she wrote, “but we must make a start.”

Parts of Cass’s review have been proclaimed as wholesale vindication by gender-critical feminists; others have been welcomed by a broad spectrum of experts and organisations. And others again have been criticised by those who fear that they amount to a repudiation of the reality of trans identities. Last night, Denis Campbell reported that NHS England is now planning a similar inquiry into patient care in adult transgender clinics.

Today’s newsletter can’t arbitrate these disagreements, provide a complete description of the 388-page report, or know how its recommendations will play out in the years to come. But it should give you a sense of the parameters of the debate. Here are the headlines.

Five big stories

  1. Middle East | Joe Biden has vowed that the US commitment to defend Israel against Iran was “ironclad” as concerns rose in Washington that a “significant” Iranian strike could happen within days. Israel has vowed to respond in kind to a direct strike, raising the prospect of a regional war.

  2. Health | Thousands of people in England who suffer from migraines are to be offered a daily pill on the NHS that can reduce the frequency of attacks by half. The newly-approved treatment is the first oral medication that can prevent both chronic and episodic migraines.

  3. Monarchy | Royal courtiers privately put pressure on the Welsh government to ensure that King Charles could not be prosecuted for rural crimes under a new law, documents reveal. The Welsh government’s chief legal adviser was “not happy” about the exemption but agreed to it last year.

  4. Julian Assange | Joe Biden said on Wednesday that he was considering a request from Australia to drop the decade-long US push to prosecute the WikiLeaks founder Julian Assange for publishing American classified documents. Assange faces 17 espionage charges and one of computer misuse, exposing him to a maximum 175 years in prison.

  5. Smartphones | Ministers are considering banning the sale of smartphones to children under 16. The government recently issued guidance on the use of mobile phones in English schools, but other curbs are said to have been considered to better protect children after a number of campaigns.

In depth: ‘Polarisation and stifling of debate do nothing to help the young people caught in the middle of a stormy social discourse’

Hilary Cass’s review was commissioned in 2020, two years after a group of clinicians at the Tavistock Gender Identity Development Service (Gids) complained that some patients were being referred for transition too quickly.

It came amid a significant rise in the number of young people referred to Gids, the only such service in England and Wales, from 250 in 2011-12 to more than 5,000 in 2021-22, a change partly driven by an increase in patients raised as girls. That increase led to waiting times for services of more than two years.

Cass published her interim report in 2022. It concluded that Gids was under unsustainable pressure, and that differing views on the right approach among its staff were causing a “clinician lottery” for patients. That led to the NHS closing the service and beginning the rollout of new regional care hubs. And in March, NHS England stopped the use of puberty blockers, except for participants in clinical research, on Cass’s advice.

The final report draws larger conclusions: for a detailed summary, see this piece by Denis Campbell and Sally Weale. Here’s what else you need to know.


Evidence for puberty blockers and hormones

A key aspect of the review was its examination of the evidence base for the use of puberty blockers and gender-affirming hormones. Cass said that a systematic review she commissioned found a continuing lack of “high-quality evidence”. She concluded that there was a limited case for puberty blockers for some trans girls and no proven case for their use for trans boys – because while they did successfully suppress puberty, they were not proven to create a “pause” for decision-making over transition, and not proven to improve psychological health.

She also said that gender-affirming hormones should only be used after the age of 16 and with “extreme caution”, but noted limited evidence that they could help with depression, anxiety, and other mental health problems.

In assessing the impact of Cass’s conclusions, it’s worth noting the numbers involved: while you might conclude from some of the coverage that Gids patients were usually given these treatments, that is not the case. Up to 2021, the Tavistock reported (pdf) that 15-20% of children and young people it saw were assessed for those treatments, with about 160 children being prescribed puberty blockers each year.

Moving away from puberty blockers and hormones follows a model used in Sweden and Finland, with concerns that most other comparable health systems are following an approach set by a single Dutch study of puberty blockers in the 1990s.

Highly influential international guidance relied on elsewhere is said by Cass to “lack developmental rigour”. Many countries continue to prescribe both, and last year the American Academy of Pediatrics said that it had commissioned its own systematic review but had “confidence that the existing evidence is such that the current policy is appropriate”.


Why some evidence was excluded

While the review Cass commissioned found dozens of studies on puberty blockers and hormones which reported a positive impact, the majority were discarded as being of insufficient rigour. “Partly it is that they’re difficult studies to design because you can’t blind people,” Cass said in an interview with the BMJ – a reference to the difficulty of ensuring that patients, doctors and researchers do not know which patients have received a new treatment.

Those exclusions have been criticised by trans advocates who say that it is an impossible standard for treatments which may have very visible impacts, and when such studies are difficult to run ethically among a child population. “The report does not appear to suggest how the ethical problems in the approach it calls for can be solved,” discrimination barrister Robin Moira White wrote for the Independent, arguing that it suggested that Cass was “content to set an impossible-to-satisfy test for trans healthcare”.

But Cass also said: “In part the biggest weakness is the length of follow-up” – that is, that there is not enough long-term evidence available. The picture could yet change, she noted in the report: “I am very aware that this is a point in time and as new evidence is gathered different insights might emerge.“


The need for better care

Cass recommends that instead of being offered mainly medical treatment, young people exploring their gender identity should “receive a holistic assessment of their needs” – with mental health and other issues addressed at the same time.

“This group of young people have been exceptionalised compared to other young people with similarly complex presentations,” she said. “They deserve very much better.” And she said there was a need to “expand capacity at all levels of the system”, with patients too quickly referred to Gids.

Part of that recommendation is the proposal for new regional centres. But only one of the eight planned is up and running, despite the closure of Gids last year and a promise that there would be at least two by now. This piece by Amelia Gentleman from last October documents some of the consequences of that shortfall.

This piece by Robyn Vinter sets out some of the anxieties felt by young trans people and their families, with one 18-year-old suggesting that the length of waiting lists should be a bigger concern than the use of puberty blockers. Meanwhile, as Tobi Thomas explains here, wider NHS pressures mean that hopes of swift access to mental health services appear remote.

Although they disagree with some parts of the review, trans advocates support the call for improved provision of care. Stephen Whittle, professor of Equalities Law at Manchester Metropolitan University, wrote on Twitter: “There are problems with Cass, but it has, at least, acknowledged a need for a properly funded service – something we have called for, for 25 years.”


Criticisms and a ‘toxic’ debate

Although Cass says that her conclusions over healthcare should be viewed separately to the constantly roiling coverage of such issues as trans access to sport and public toilets, she does note that that climate has had an impact on both patients and on her work.

“The toxicity of the debate is exceptional,” she wrote. “Polarisation and stifling of debate do nothing to help the young people caught in the middle.”

But some have read her warning as appearing to apply only to one side of the argument: she refers to healthcare professionals being afraid to discuss their views for fear of being labelled “transphobic”, but has nothing to say about whether a sharp increase in media coverage hostile to trans people might cut the other way, for example. Cass might respond that such concerns fall outside her remit.

Others have complained that she gives undue prominence to detransitioners, who are discussed at some length in the report. Cass writes that while there is a “lack of clear data on how frequently detransition or regret occurs in young adults”, there is a “suggestion” numbers are increasing. But a 2021 review of 27 international studies involving 8,000 trans teens and adults found about 1% expressed regret – a lower rate than that for many medical procedures.

Despite all this, there is at least a fragile consensus that Cass’s review is a seriously intended and robust piece of work. In this piece, as well as noting significant objections, the journalist Freddy McConnell lists a range of points on which he agrees with Cass, drawing partly on his own experiences as a trans man.

But he also predicts that Cass’s review will be used to “perpetuate a broader hostile environment towards trans people in the UK” – and that if this happens, “the young people she has tried to help will, understandably, feel betrayed.”

What else we’ve been reading

  • It gives me great pleasure to point you to Hannah Marriott’s piece about some very vulgar rich people who are angry with Hermès for not selling them Birkin bags (above), and the insane economics of “artificial scarcity”. “Literally speaking, the Hermès Birkin is just a bag,” she notes drily. But it’s so much more than that! Archie

  • Much of the conversation around a potential (and probable) Labour government revolves around where the money will come from to make much-needed improvements to public services. Richard Murphy argues persuasively that Rachel Reeves can find an extra £90bn a year to spend with five simple policy ideas. Toby Moses, head of newsletters

  • Aditya Chakrabortty coins a memorable definition of Britain’s decline in a question: “How do people live when money has discarded them?” His exploration of the answers on a visit to the south-west Durham town of Shildon makes a powerful case that for all the blame attached to Brexit and Boris Johnson, “the problems facing the UK go back decades”. Archie

  • Ann Lee interviews actor Jing Lusi about the stereotypes that dogged her early career as the Crazy Rich Asians star becomes the first of east Asian heritage to lead a big British drama: “All I got was prostitute, takeaway worker and illegal immigrant that would sleep with anything for a visa. You have to put on an accent. I’d just graduated in law at UCL. I was, like: ‘Is this how you see us?’” Toby

  • Today’s long read, by the Palestinian-American historian Rashid Khalidi, is an essential examination of how the conflict in Gaza fits into what he calls “the hundred years’ war on Palestine”. Even in that context, he writes, the last six months “mark a new abyss into which the struggle over Palestine has sunk”. Archie


Champions League | A frantic quarter-final first leg at the Parc des Princes finished 3-2 to Barcelona after two goals from Raphinha (above) helped the visitors come from behind against Paris Saint-Germain. The night’s other match finished 2-1, with a late goal from Dortmund’s Sebastien Haller giving the away side hope after first half strikes for Atlético from Rodrigo De Paul and Samuel Lino.

Olympics | Sebastian Coe has defended World Athletics’ decision to break with 128 years of Olympic tradition by becoming the first sport to give athletes prize money if they are victorious in Paris this summer. Coe said the surprise move, under which gold medal-winning athletes in each of the sport’s 48 events will walk away with $50,000 (£39,360), was merely a reflection that the world has changed.

Women’s football | Rachel Daly, a member of the England squad that won Euro 2022 and reached last year’s World Cup final, has announced her retirement from international football. The 32-year-old Aston Villa forward won 84 senior caps for the Lionesses, scoring 16 goals. “I would love nothing more than to play for England forever, but the time has come for me to hang my boots up on the international stage,” she wrote.

The front pages

The Guardian leads with “Biden declares ‘iron clad’ support for Israel amid fears of Iran attack”. The Telegraph follows the same story with “Biden warns Iran not to attack Israel”.

There is a range of stories on other front pages, with the Times leading on “Sickness claims rise hits Tory heartlands”. The Financial Times reports “Markets slash rate cut bets as US inflation climbs to 3.5%”. The i has “Labour plans to fix UK buses with public ownership of failing services”.

The Daily Mail says “China is flooding Britain with fake stamps”, and the Daily Express reports a “Radical NHS plan to fast track care and free up beds”. The Mirror carries an exclusive from the mother of Caroline Flack, under the headline “I will get the truth”. Finally, the Sun reports on a police crack-down at the Grand National with “Ring of steed”.

Today in Focus

Stormy Daniels, Donald Trump and the start of the hush money trial

Hugo Lowell talks through the law and the politics of a case starting this Monday against Donald Trump – the first ever criminal trial of a former or sitting US president.

Cartoon of the day | Ben Jennings

The Upside

A bit of good news to remind you that the world’s not all bad

Ten years ago, Claire McGowan’s life was not going the way she had planned. She was broke after a divorce, was living in a mouldy basement flat, and the perfect marriage, kids and house in a quaint town did not seem to be on the horizon. So McGowan (picture skiing in Bulgaria in 2013, above), then 32, made a plan to work through everything on her “try before you’re 30” bucket list. True, she was two years overdue, but the timing seemed right to do everything from take a standup comedy course, study Spanish, run a 10k race and – for reasons she doesn’t explain – let a tarantula walk over her hand.

“I tried it all,” McGowan writes in the latest instalment of A moment that changed me. Her adventurous attitude not only turned her life around, but has given her a lasting mindset to try, and fail, at new things. “My divorce taught me that good things lie on the other side of fear,” she writes. “I now believe that the trick is to ride out the fear, or just admit to being way out of your comfort zone.”

Sign up here for a weekly roundup of The Upside, sent to you every Sunday

Bored at work?

And finally, the Guardian’s puzzles are here to keep you entertained throughout the day. Until tomorrow.