The Observer view on gender identity services for children

The Cass review’s interim report finds children with gender identity issues are ill served by adults who shut down debate

Ideology has no place in medicine. An individual’s healthcare must not be influenced by a clinician’s biases. But an independent review has highlighted that the quality of care for children with gender dysphoria in England has been unconscionably compromised in recent years, partly as a result of adult affinities to an unevidenced worldview.

The review, led by the distinguished paediatrician and former president of the Royal College of Paediatrics and Child Health Dr Hilary Cass, has published its interim report. Its findings echo concerns already flagged by the courts, the Care Quality Commission, and, as the Observer has reported over the years, several NHS whistleblowers.

The report highlights a profound lack of evidence and medical consensus about the best approach to treating gender dysphoria in children. Yet the NHS’s specialist Gender Identity Development Service (GIDS) takes a child’s expressed gender identity as the starting point for treatment. This “affirmative approach” leaves little space for exploration of the potential relationship between their dysphoria and neurodiversity or psychosocial needs, including those arising from childhood trauma or internalised hostility to same-sex attraction. GIDS has compounded this lack of evidence with its own failure to track patient outcomes.

As referrals to GIDS have increased, capacity has not kept up, meaning that children face unacceptably long waits for care. Also, it has been applying the affirmative model in a looser form than in the Netherlands, where it was conceived, and to a patient group whose characteristics have changed dramatically from those for whom it was developed – teenage girls, whose gender dysphoria has manifested in adolescence rather than in early childhood. The majority of young people now referred to GIDS have other complex mental health issues or neurodiversity, but GIDS has failed to assess these needs in the round.

The review is also clear about the lack of evidence about one of the affirmative model’s treatment pathways: puberty-blocking drugs, which, for the vast majority of children prescribed them, function as a precursor to cross-sex hormones. The long-term health consequences of puberty blockers are unknown, and there is clinical confusion about their purpose. It is unclear whether children progress to cross-sex hormones because their gender identity was already settled, or whether puberty blockers interfere with the natural resolution of gender dysphoria.