Medical Transition for Children - Where Are We Now?
The Final Report of the Cass Review was published on 10th April 2024 and the landscape has shifted back to protecting children and gathering evidence. How did we get here? And where are we going now?
How did we get here?
I am looking forward to discussing these issues in more detail at Genspect’s September conference in Lisbon, in the context of the tension between paternalism and autonomy when protecting children.
For what appears to be the first time in recorded history we are presented with a childhood ‘identity’ which requires scaffolding by medical or surgical interventions. Unlike the mods, rockers or goths of old who relied on their clothes, hairstyles and musical tastes to signal their tribe, ‘gender distressed’ children who wish to adopt a ‘gender identity’ which does not match their sex at birth, are told they must embark upon medical and surgical intervention which requires a lifelong commitment and irreversible physical changes.
It is not for me to determine if the recent surge over the last decade of the numbers of children seeking medical treatment for their ‘gender distress’ is a result of social contagion or more open societal attitudes to childhood transition. The fact that the majority of the children referred to the Tavistock in recent years were born female and many were also autistic, suggests that social contagion is the more likely explanation.
Regardless, the treatment offered is controversial because it lacks a firm evidence base for its efficacy or safety and has irreversible consequences. The biological risks are significant. There is no compelling evidence to support a claim that puberty blockers are ‘reversible’ , The evidence suggests instead worrying implications for bone density and neurological development. The ingestion of testosterone for female children risks vaginal and uterine atrophy, and for all children, cross sex hormones risk loss of fertility and adult sexual function.
As discussed by Stephen B Levine in 2018, writing for the Journal of Sex and Marital Therapy Informed Consent for Transgendered Patients, there are also significant psychological risks, involving deflection of necessary personal development challenges, inauthenticity and demoralisation – when changing your body does not bring about the desired changes to the way you ‘feel’.
The Court of Appeal noted in Bell v Tavistock at para 3
The treatment of children for gender dysphoria is controversial. Medical opinion is far from unanimous about the wisdom of embarking on treatment before adulthood. The question raises not only clinical medical issues but also moral and ethical issues, all of which are the subject of intense professional and public debate. Such debate, when it spills into legal proceedings, is apt to obscure the role of the courts in deciding discrete legal issues.’
Despite the law recognising that sex is binary and gender identity is a social construct – see Elan- Cane v Secretary of State for the Home Department [2018] 1 WLR 5119 and Maya Forstater v CGC Europe UKEAT/0105/20/JOJ para 35 – alongside the soaring referrals to the Tavistock, increasing prominence was given to the view that ‘gender identity’ is a more important and relevant organising category than biological sex, and those who disagreed were displaying inherent and unacceptable discrimination against ‘trans identifying’ individuals. Charities such as Mermaids declared that a child of ‘any age’ who said they were trans was likely trans, and any attempt to put age limits on access to treatment was unacceptable and bigoted ‘gatekeeping’.
This is despite what we know about the developing teenage brain, which is reflected in the 2022 Scottish sentencing guidelines for young people up to the age of 25. Sentencing Children and Young People – Sentencing (sentencingcouncil.org.uk)
Children and young people are not fully developed, and they have not attained full maturity. As such, this can impact on their decision making and risk-taking behaviour. It is important to consider the extent to which the child or young person has been acting impulsively and whether their conduct has been affected by inexperience, emotional volatility or negative influences. They may not fully appreciate the effect their actions can have on other people and may not be capable of fully understanding the distress and pain they cause to the victims of their crimes. Children and young people are also likely to be susceptible to peer pressure and other external influences and changes taking place during adolescence can lead to experimentation…
Giving primacy to gender identity over sex, and ignoring the clear evidence about adolescent cognitive maturation, has had inevitable consequences for the general approach to childhood medical transition, shifting the focus from the best interests of the individual child to support for a more general ideology.
Unease over the medical transition of children spilled over before the Divisional Court in Bell in 2020. The court displayed palpable unease at the lack of record keeping by the Tavistock and the uncertain evidential base for the treatment, and made various declarations about how children should be treated. This was then overturned, the Court of Appeal determining that the lower court had gone far beyond the permissible parameters of a judicial review and attempted to fetter the clinical discretion of doctors. This is not the job of any court, but better left to Parliament or the profession itself.
However, the unease highlighted in the initial court judgment, was shared by many. Following Bell the NHS commissioned the Cass Review - an independent and expert review into all aspects of child hood medical transition, led by Dr Hilary Cass.
The interim report published in 2022 carried out a thorough review of the existing evidence base to support medical transition of children. It concluded the evidence was weak and that children should not be given puberty blockers unless part of a clinical trial. In March 2024 the NHS confirmed that no child would be prescribed puberty blockers unless as part of a clinical trial and set out some very strict ‘inclusion criteria’ before a child could access ‘gender affirming hormones’ from 16 years. This includes assessment of the child’s understanding of the impact on their fertility and their ability to weigh the benefits and risks of the treatment.
However, those for profit private providers of blockers and hormones, have declared that they will not follow the NHS lead. The Webberleys for example are a particularly alarming husband and wife team behind GenderGP, an organisation based in Singapore to escape regulation in the UK.
Dr Mike Webberley was struck off the UK medical register in 2022 after the Medical Practitioners Tribunal Service found ‘wide ranging failings’ in treating young transgender patients; he had provided treatment that was not clinically indicated or that had been prescribed without adequate tests, assessments, or examinations – See Dr Michael Webberley (2620107) Determination of the Facts – 18/05/22 https://drive.google.com/file/d/1Xsv8zghhgvbzCSZADpaFGeTxgMemS9hq/view?usp=sharing. The youngest child given puberty blockers by Dr Webberley was 9 years old.
Dr Helen Webberley faced similar disciplinary proceedings, for inter alia, prescribing testosterone to an 11 year old girl without ever discussing fertility issues. She managed to escape being struck off but was criticised for her sloppy record keeping. Far from learning any lessons, she has doubled down. announcing via Gender GP’s website on 15th March 2024 Message from Dr Webberley - We stand with WPATH - GenderGP Transgender Services
GenderGP will not be following the NHS guidance, it will be following International Guidelines and best practice which means puberty blockers for transgender children when they are seeking to prevent the changes that will happen to their bodies during puberty. And it means providing gender-affirming hormones to allow that child to go through the puberty that matches their gender identity.
The final Cass Report
This was published on 10th April 2024 and you can download it here. It is sadly clear that in the area of childhood medical transition, the pillars of evidence based medicine are shaky indeed. Dr Cass notes in her foreward ‘this is an areas of remarkably weak evidence’ and some practitioners ‘abandoned normal clinical approaches to holistic assessment’.
It is very sad to note what she then says
Despite the best intentions of everyone with a stake in this complex issue, the toxicity of the debate is exceptional….There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop. Polarisation and stifling of debate do nothing to help the young people caught in the middle of a stormy social discourse, and in the long run will also hamper the research that is essential to finding the best way of supporting them to thrive.
Since the interim report, the Cass Review commissioned the University of York to conduct a series of systematic reviews to examine:
the evidence about the characteristics of the cohort presenting to gender services
the outcomes of social transition
psycho social interventions
and endocrine treatments - the provision of masculinising or feminising hormones
These findings regarding all were ‘disappointing’ and suggest that the majority of clinical guidelines have not followed the international standards for guideline development. There is particular criticism for the World Professional Association of Transgender Health Care (WPATH) which has been influential in directing international practice, but its guidelines were found to lack developmental rigour and transparency.
Dr Cass notes that the rationale for early suppression of puberty remains unclear, as does the evidence on the impact of mental or psychosocial health. The effect on cognitive and psychosexual development remains unknown.
A particularly worrying gap in the evidence relates to the more recent cohort of female children who frequently present with other co-morbidities such as adverse child hood experiences, autism and a range of mental health challenges.
The report makes Key recommendations, focusing on the need for more and better evidence and more and better information. I particularly welcome the recommendations on revisiting current treatment standards re cross sex hormones for 16 year olds, and recognition of the dangers of potentially inappropriate prescribing from unregulated and for profit providers.
There should be a nominated medical practitioner who takes overall clinical responsibility for patient safety
Children must receive a holistic assessment of their needs, including screening for neurodevelopmental conditions
Psychological approaches should be used to support management of distress and include support for wider family members
If decisions are being considered about social transition of pre-pubertal children, they should be seen as early as possible by clinical professional
NHS England should direct gender clinics to participate in research
The evidence base underpinning interventions in this area must be improved.
Long standing gender incongruence is an essential pre-requisite for medical treatment but only one aspect of deciding the right pathway for the individual.
NHS England should review its policy on providing cross sex hormones to 16 year olds.
Every case considered for medical treatment should be discussed at a Multi Disciplinary Team
All children should be offered fertility counselling and preservation prior to going onto a medical pathway.
NHS England should work to develop regional multi site service networks as soon as possible.
The National Provider Collaborative should be established without delay.
Joint contracts should be used to support staff to work across the network and across different services.
NHS England must ensure requirements for this service area are built into overall workforce planning for adolescent services.
NHS England should commission a lead organisation to develop a competency framework, identify gaps in training and develop training materials.
The National Provider Collaborate should coordinate development of evidence-based information and resources.
A core national data set should be defined.
infrastructure in place to manage data collection and audit, to drive continuous improvement and active learning.
Ensure infrastructure to support clinically based research is embedded into regional centres.
Establish a unified research strategy
Commission a living systematic review to inform the evolving clinical approach.
Establish separate pathway for pre-pubertal children.
Establish follow through services for 17-25 year olds at Regional Centres
Bring forward any planned update of adult service specification, to review the model of care.
Ensure support for detransitioners.
Consider the implications of private health care on any future requests for NHS treatment.
Define the dispensing responsibilities of pharmacists re private prescriptions and consider statutory solutions to prevent inappropriate overseas prescribing
Review the process of changing NHS numbers.
NHS England to develop implementation plan for future clinical and service model
NHS England should establish robust management of the collection of data.
Professional bodies must come together to provide leadership and guidance.
Wider guidance should be developed, to ensure innovation is encouraged but appropriate scrutiny to avoid ‘incremental creep of practice in the absence of evidence’.
Conclusions
The key message from the final Cass Report, is that we need better evidence to justify what is currently being done to children in the name of ‘gender identity’. Gender questioning children must be able to access a broad based holistic assessment delivered by a multi professional team. They deserve no less than other children presenting with complex needs. Medical intervention cannot be the first, or only option.
Whether or not that is achievable and in what time frame, given the current pressure on existing services remains to be seen. But this is a very welcome and necessary corrective to the current assertions that treatment for childhood ‘gender distress’ is well evidenced, not to be questioned, and must simply be offered as soon as possible - and if you challenge this, you are disgusting bigot. The new regional centres set up after the closure of the Tavistock will act to collect evidence to inform best practice.
While that data is gathered, it will now be for Parliament to consider whether there needs to be changes to the law to protect young people from accessing medical treatment with such an uncertain evidence base and such significant consequences. A child of 17 can currently ‘self refer’ to NHS adult services, which does not require the same degree of detailed assessment as children’s services. It is very reassuring that the Cass Report recommends further consideration about this, extending support to children up to the age of 25.
The sad reality of NHS long waiting lists means that in any event children are likely to well into adulthood before they get an NHS appointment. This underscores the urgent need to restrict the private for-profit gender identity ideologues from undermining the NHS safeguards. A judicial review has just been launched against the decision by the Care Quality Commission (CQC) to register Gender Plus Hormone Clinic to provide hormone treatments to 16 and 17-year-old children. You can support the crowdfunder here. The need to act now against private providers is recognised by Sajid Javid, who kickstarted the whole process of the Cass Review.
While we wait for better evidence to support the sterilisation of children in pursuit of a ‘gender identity’, it is worth reminding ourselves that the court retains an inherent jurisdiction to protect all children from significant harm. The court has the power to override the wishes and feelings of any child, even one with capacity. The court approaches its task as the ‘reasonable judicial parent’ described in this way by Sir James Munby at para 21 An NHS Trust v X [2021] EWCH 65 (Fam). He referred to his previous judgment in Re G (Education: Religious Upbringing) [2012] EWCA Civ 1233 when asking the question – what are the judge’s aims and objectives when acting as a ‘judicial reasonable parent’? One of three answers was this:
Thirdly, our objective must be to bring the child to adulthood in such a way that the child is best equipped both to decide what kind of life they want to lead – what kind of person they want to be – and to give effect so far as practicable to their aspirations. Put shortly, our objective must be to maximise the child's opportunities in every sphere of life as they enter adulthood. And the corollary of this, where the decision has been devolved to a 'judicial parent'', is that the judge must be cautious about approving a regime which may have the effect of foreclosing or unduly limiting the child's ability to make such decisions in future.
Some useful authorities
Re W (A Minor) (Medical Treatment: Court's Jurisdiction) - Case Law - VLEX 804572145
A Primary Care Trust v P & Ors [2009] EW Misc 10 (EWCOP) (21 December 2009) (bailii.org)
J (A Minor), Re [2016] EWHC 2430 (Fam) (21 October 2016) (bailii.org)
Mrs S Appleby v The Tavistock and Portman NHS Foundation Trust: 2204772/2019
EMPLOYMENT TRIBUNALS (publishing.service.gov.uk)
AB v CD & Ors [2021] EWHC 741
Re: Imogen (No. 6) [2020] FamCA 761 (10 September 2020) (austlii.edu.au)
Serious Medical Treatment, Guidance [2020] EWCOP 2 (17 January 2020) (bailii.org)
An NHS Trust v Child B & Ors [2014] EWHC 3486 (Fam) (01 August 2014) (bailii.org)
Maya_Forstater_v_CGD_Europe_and_others_UKEAT0105_20_JOJ.pdf (publishing.service.gov.uk)
Just as it is illegal, I believe, for any person in the U.K. to assist another to travel to Switzerland to utilise the services of Dignitas, it should be equally illegal to assist a child to visit the Webberleys’ overseas clinic.
Thanks Sarah. I'd like to point out, however, that the cause for the sex-based difference that's emerging in use of 'gender services' is bigger and more complex than some sort of amorphous 'social contagion' -- it's misogyny that promotes and supports sexualisation of girls/women, homophobia, objectification and fragmentation (eg, the mind.body split) that is facilitated by digital technologies and fast communication via the internet and able to be viewed and used in privacy away from parental supervision.