Cass report sparks concerns over treatment for trans adults under 25

A recommendation in the Cass report to create a “follow-through service” for trans 17-25 year olds has concerned experts.

The review into England’s youth gender services was published on Wednesday morning (10 April) after a wait of four years.

NHS England commissioned paediatric expert Dr Hilary Cass to head a review in 2020 in response to the sharp rise of referrals to what was then England’s only youth gender clinic.

Alongside an interim report from 2022, the Cass Report makes upwards of 32 recommendations, including a decentralised approach to healthcare in the form of regional hubs across England.

Its 23rd recommendation urges NHS England to establish a “follow-through service” for 17-25 year olds on the gender care pathway.

The recommendation says that clinics should each establish a service for those transitioning to adult Gender Identity Clinics (GICs) “either by extending the range of the regional children and young people’s service or through linked services.”

It argues that this would help to “ensure continuity of care and support at a potentially vulnerable stage in [a trans person’s journey” and would also “allow clinical and research follow-up data to be collected.”

The recommendation has sparked concern among experts who say that other recommendations made in the report could result in under-25s losing access to much-needed hormone treatment.

As well as establishing separate pathways for pre-pubescent and teenage patients, the Cass Report also urges clinicians to exercise “extreme caution” in prescribing feminising or masculinising hormones from age 16 above, saying there needs to be a “clear clinical rationale” for the decision.

If implemented, “follow-through services” would extend the age range for which these recommendations would apply.

What do the experts say?

Clinical psychologist and director of the independent gender service, Gender Plus, Dr Aiden Kelly expressed concern over several of the recommendations, urging officials to refrain from making “anyone’s life harder or more complicated than it needs to be.”

On the proposed follow-through services, Kelly said that he sees the “merits” in implementing such a transitional service, adding that, if done correctly, would address a large chunk of referrals, which he said “come between the ages of 15-25 years.”

“With the current waiting lists stretching into years, the existing NHS model essentially results in trans youth ageing out of children’s service and into adult service often before they even have their first appointment.

“This solution would address that and is similar to our approach at Gender Plus.”

But, like many others, Kelly is fearful of how the Cass Report will be implemented, saying it’s “hard to remain hopeful” of a significant change on the ground.

He specifically pointed to the new regional hubs which opened for preliminary care in April. A whistleblower said that the hubs were “nowhere near ready” earlier this month.

“I’ve no doubt that much of what’s been written in these reports won’t be able to be fully implemented,” Kelly said.

“These were already seen with these early regional hubs. They don’t know how to fill these positions.”

In a statement to PinkNews on the report, Stonewall’s director of campaigns and human rights, Robbie de Santos, said that while many of the recommendations could prove positive, he urged “due care” was need to avoid creating new barriers for trans people.

“Without due care, training or further capacity in the system, other [recommendations] could lead to new barriers that prevent children and young people from accessing the care they need and deserve,” he said.

“We urge NHS England and policymakers to read and digest the full report.”