NHS plans review of adult gender services after Cass criticism

The NHS has drawn up plans for an inquiry into the safety of gender care for adults, in response to detailed concerns raised by the author of the Cass report into gender care for children and young people.

Dr Hilary Cass, the chief paediatrician, raised 16 separate concerns about the quality of treatment for adults with gender dysphoria in a sharply worded letter to NHS England.

In response, NHS officials have committed to a judgement of these services and announced that clinic inspections would begin in September.

Cass said that during her three-year research into gender services for children, she was contacted by a number of staff working in adult gender clinics. They reported inadequate consent processes, limited explanation of the risks involved in treatment, “chaotic” administrative processes, “excessive” waiting lists, a lack of national treatment guidelines regarding the use of hormones and a lack of systematic processes for follow-up.

Cass was told that patients were not always informed about “the irreversibility of some effects” of the treatment. Some clinicians told her they were concerned that their colleagues were not correcting or challenging patients’ “magical thinking,” “i.e. unrealistic beliefs about what could be achieved through medical transition,” she wrote in the letter, sent in May and published on the NHS England website earlier this month.

Following these reports, NHS England has published details of a new review, to be led by Dr David Levy, which will assess not only the quality (ie effectiveness, safety and patient experience) and stability of each service, but also whether the existing service model is still appropriate for the patients it cares for.

Levy, a cancer specialist and medical director of the Lancashire and South Cumbria Integrated Care Board, is supported by a panel of expert clinicians, patients and representatives from the Care Quality Commission.

NHS England has also published details of its plans to expand services for young people, improve training for staff, enhance research and explore what support can be offered to patients who want to reverse their gender reassignment.

Cass wrote that she had heard concerns from some clinicians working in adult gender care that the approach to care was “ideologically driven and polarized and that it was difficult to question the approach or discuss concerns.

“A common concern was the very limited time for assessment and the expectation that patients would receive hormones on their return visit,” she wrote. “Most patient presentations were extremely complex, with a mix of trauma, abuse, mental health diagnoses, forensic history, ASD, and ADHD, and therefore this limited assessment was inadequate.”

Concerns were raised “about the marked change in the case mix from predominantly older, registered at birth males to predominantly registered at birth females in their early 20s with complex symptoms,” she wrote.

The Cass report on childcare, published in April, recommended ‘follow-through services’ for 17- to 25-year-olds, to prevent young people being immediately drawn into a radically different adult care model.

The Cass report was welcomed by both Labour and Conservatives, and NHS England upon publication. However, the British Medical Association last month voted in favour of a motion criticising the review and calling for a pause in the implementation of its recommendations.

A spokesperson for Cass Review defended the research standards.