Independent Review of Gender Identity Services for Children and Young People: The Committee will take evidence from—
Dr Hilary Cass, Chair, The Cass Review
Dr Hilary Cass, Chair, The Cass Review
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00:00 Thank you. The second item on our agenda is an evidence session with Dr. Hilary Cass
00:05 concerning her review of gender identity services for children and young people
00:10 commissioned by NHS England. Dr. Cass is joining us remotely and I welcome her to
00:16 the committee. She was the chair of the Cass review. We will move straight
00:23 to questions. Thank you for your time. I will go to Ruth Maguire.
00:30 Thank you, convener. Good morning, Dr. Cass. Thank you for being with us this morning.
00:38 Your review is obviously a really detailed piece of work that needs careful consideration.
00:45 We all appreciate that it was based on services in England but will have implications for how
00:52 children are treated in Scotland. There is learning for us all in that. Can you start
00:58 off by talking about the key conclusions that you would want us here in Scotland to draw
01:05 from this work in order to do the best for children in distress?
01:17 As will be clear from the report, the main issue of concern for me was the weakness of
01:25 the evidence base, and that is across all aspects of care. Critically, we need to work
01:35 collaboratively as broadly as we can, both nationally and internationally, to try to
01:42 improve that evidence base. The second piece of learning from England was that, firstly,
01:54 children were being bypassed because they were not getting basic assessments locally.
02:01 Often they were bypassed straight through to the JID service at Tavistock. Crucially,
02:09 and I think this is transferable, these young people need a very broad multidisciplinary
02:15 approach to care because they often have complex presentations, and just seeing them through
02:22 a gender lens means that they do not get the breadth of care that they need. I think those
02:29 are the two messages that apply regardless of where in the UK or internationally you
02:38 are.
02:39 Thank you. That is helpful.
02:42 Thank you. Tess White.
02:45 Thank you. Good morning, Dr Cass. In relation to the 32 recommendations from a very comprehensive
02:53 report, is there anything specific in relation to the delivery of services that you believe
03:01 could apply in a Scottish context? Thank you.
03:06 Yes. I think some of the things that I just alluded to, particularly in England, we are
03:18 embedding these services within a broader children's hospital service setting so that
03:25 there is access to services for young people with autism, with eating disorders, with a
03:34 range of other presentations, so that they do get looked at holistically. Also, I think
03:44 both the research and the clinical approach, which is going to be regionalised, should
03:53 the Scottish Government and health service feel that it was helpful, there is scope both
04:00 to include Scotland within the research infrastructure that we are setting up in England and also
04:11 within the regional network where there is the ability to share and support clinical
04:18 practice. Clearly, that is a decision to be made in Scotland. It is certainly something
04:24 that I think we would welcome in England.
04:28 Thank you. My second question, if I may. In your opening, to answer Ruth Maguire's question,
04:35 you talked about the importance of evidence base and collaboration. How do you think that
04:41 certain factions of the Scottish Green Party have said that your work is a social murder
04:52 charter?
04:55 I think it is not for me to comment on any political opinion in Scotland. I think my
05:01 job is to comment on the evidence as I see it. If that were to be framed into specific
05:11 questions or concerns about my conclusions or the work, I would be happy to answer them.
05:19 What key conclusions would you want practitioners in Scotland to draw from the review in terms
05:27 of future provision for gender services?
05:33 I think it is important that young people get a holistic assessment, and that includes
05:43 looking at all aspects of their presentation and trying to understand the gender questioning
05:54 in the context of other issues that are happening for them. One of the problems in just focusing
06:03 on the gender is that you can end up putting somebody on an end-grind pathway when you
06:16 have not addressed the fact that they have undiagnosed autism, they are out of school,
06:21 they are not participating, there is a family breakdown and all those other factors. I think
06:27 it is about seeing them as a young person first and understanding the gender distress
06:32 through that lens. I think accepting that two things are simultaneously true. Firstly,
06:40 a small number of these young people are going to benefit from a medical pathway for their
06:47 gender distress, but equally for a larger number, their gender distress is going to
06:55 be resolved in a myriad of other ways, whether that is through a developmental questioning
07:04 period that spontaneously resolves, or whether they resolve uncertainty about their sexuality
07:13 and then their gender questioning resolves, or whether they find that they do not want
07:19 a very rigid medical pathway but just remain gender fluid or gender non-conforming in the
07:26 longer term. I think it is about being open and exploring and making sure that options
07:33 are not foreclosed too soon for that young person. I think that is probably the single
07:39 most important takeaway.
07:44 Thank you for that answer. Ivan McKay.
07:46 Thank you. Good morning, Dr Cass. Thank you for spending some time with us this morning.
07:51 You have rightly mentioned that the evidence base is a hugely important part of the work
07:55 that you have undertaken, and clearly that has gained a bit of traction in the discourse
08:00 following your report. It would be good to give you the opportunity to talk through the
08:08 approach that was taken in assessing that evidence in terms of the systematic review
08:14 methodology and what evidence was included and what was not included as part of that
08:20 assessment, and why.
08:26 The systematic reviews were carried out by the University of York, which was one of a
08:30 small number of organisations that are commissioned by the NHS to carry out systematic reviews.
08:40 It was overseen by the head of that department. They looked at a very wide array of papers,
08:51 well in excess of 200 across all areas, but the papers that have got most attention are
08:59 the ones that have focused on puberty blockers and masculinising and feminising hormones.
09:06 There were 102 papers that were included within that search. There has been significant misinformation
09:15 about those, and I hope that is now corrected in everyone's minds. Just to be clear, there
09:22 was an incorrect piece of information being circulated that 98% of those papers had been
09:32 disregarded and that only randomised controlled trials were included. Both of those things
09:38 are wrong. There were no randomised controlled trials, but there were still two high-quality
09:47 papers and some 50 moderate-quality papers. So, overall, 58% of the 102 papers were included
10:03 within the analysis because they were high or moderate quality. Those papers included
10:14 a whole variety of different studies, mainly what's called cohort studies, where you follow
10:21 up and compare groups or look longitudinally, and they're not randomised controlled trials,
10:29 but they're still accepted as good evidence if they're conducted well. The significant
10:43 weaknesses was that the follow-up periods were not long enough, that there was significant
10:48 loss to follow-up, so you started off with a larger sample, and because significant numbers
10:56 fell out during the course of the study, it made it hard to draw conclusions that the
11:02 comparison groups weren't appropriate. So, it was a very poor literature compared to
11:08 most other literature, including in children's healthcare practice. So, that was quite striking.
11:19 The evidence for the efficacy of both puberty blockers and masculinising and feminising
11:27 hormones was weak, and we are still unclear about potential adverse effects. If the committee
11:36 wants, I can say a bit more about puberty blockers, because that's been a source of
11:41 contention.
11:42 I think we'll come on to that in follow-up questions. Thanks very much. That's great,
11:49 because you've answered some of my supplementary questions as well. It's true to say that this
11:57 supposed statistic of 96% or 98% of the evidence being ignored is (a) wrong and (b) the evidence
12:02 that wasn't included—which sounds to be about less than half of it—wasn't included
12:06 because it wasn't a robust enough methodological approach to be included in the work that York
12:11 University carried out. That's good. The other point I was going to ask about was how this
12:17 compares to methodologies as applied in other areas of paediatric medicine, but I think
12:22 you've answered that by saying it significantly falls short of what you would see in other
12:27 areas.
12:28 I wanted to move on and ask you about how we fill those gaps. What research is under
12:34 way at the moment? Is it sufficient? What else needs to be done? How long will it take
12:38 for us to build up an evidence base that allows us to address these questions more robustly?
12:47 On the last question, there has been the question of whether we have set a higher bar for this
12:53 research or for this systematic review, and we absolutely haven't. I think, in terms
13:00 of the bar we should set, these young people should get the same standard of evidence in
13:05 their care as every other young person. So, just to say that.
13:10 Where we are in England, there is a puberty blocker trial being designed that will have,
13:18 obviously, involvement from service users, but the lead investigator has been appointed
13:25 and a group has started to come together to think about that. There is potentially going
13:33 to be some international collaboration on that. But I feel that we really need every
13:42 young person who walks through the door, ideally, to agree to be part of some kind of study
13:49 and follow-up, because it is just important for us to understand what happens to the young
13:54 people who do not go on a medical pathway, as those who do understand what aspects of
14:01 care, both medical and non-medical, were helpful for the whole group. That does mean following
14:08 young people up into adulthood, including those who go on a medical pathway. Obviously,
14:18 we cannot compel anybody to be followed up into adulthood, and a lot of that is about
14:24 rebuilding trust with young people so that they wish to be part of a study into adulthood
14:33 to help the young people coming behind them.
14:35 That is great, thank you. Just to be clear, what questions would you hope that the research
14:41 and future evidence would give us the answers to?
14:47 We want to understand if there is a small group of young people who do benefit from
14:54 puberty blockers. We also want to understand what any potential negative effects there
15:02 might be on that, particularly for broader brain development and psychosexual development
15:13 and bone health and other physical health indicators. We want to understand more about
15:22 which young people may benefit in the longer term for going on to masculinising or feminising
15:31 hormones. The real challenge is that young people's sense of self and gender identity
15:39 continues to evolve into young adulthood, and we do not have an accurate way of predicting
15:46 who will have a long-term stable trans identity. The more we are able to be really clear about
15:56 who has a successful long-term outcome and who has an outcome that does not meet their
16:04 aspirations, the better that will be. We also need to understand what are the things that
16:10 matter in the longer term to those young people. It is not just about can you successfully
16:19 achieve a medical transition; we know that we can do that. It is about whether people
16:26 in the longer term are participating, whether they have a job, whether they have a partner,
16:31 whether they are happy with their sex life, whether they are psychologically well. All
16:42 of those things are important.
16:44 So that would be looking at physical and mental outcomes from a health perspective?
16:49 Yes, and social outcomes.
16:51 That would also look at people who chose to detransition at a future stage?
16:57 Yes. I think there has been anxiety about looking at the trans community being concerned
17:05 that we are looking at detransitioners to say that we should not be giving gender-affirming
17:10 care. I think the important thing about understanding people who do detransition is what were the
17:18 factors that led them to detransition? Were there earlier signs that this may not have
17:24 been a successful pathway for them? Those are things that you can then build into the
17:32 equation that you discuss with somebody coming through so that they know what the likely
17:41 risks are for them as an individual. It is the same as any medical intervention where
17:47 you look at somebody who has a less successful outcome. You then explain that to people who
17:53 want to undergo that same procedure to inform them. That is not telling them they cannot
17:59 do it; it is saying that those are the risks that we are aware of.
18:03 That is great. Thank you very much.
18:05 Thank you. Emma Harper.
18:07 Thank you, convener. Good morning, Dr Cass. Thank you for being here this morning. I am
18:13 interested to hear about one of the recommendations about how young people should remain within
18:19 a service from the age of 17 to 25. The recommendation says that NHS England should ensure that each
18:30 regional centre has a follow-through service for 17 to 25-year-olds, either by extending
18:36 the range of the regional children and young people service or through linked services.
18:43 I am interested to hear how that recommendation means that young people should stay under
18:52 the care between the ages of 17 and 25. How would that work in practice? There has been
19:02 some misrepresentation that says that that means that no one will be able to transition
19:08 before that age.
19:10 Yes, there has been a lot of misunderstanding about this recommendation as well, as you
19:19 rightly say. The reason we propose this is that it is in line with other aspirations
19:27 that NHS England has for longer-term services for young people, both mental health and cancer,
19:35 and it is about continuity of care. The worst possible time to transfer services is when
19:45 you are at a critical point in your gender transition around 17 to 18. We know that that
19:52 has been a high-risk time when young people get lost between the children's and adult
19:57 services. There are problems in managing their medication through that period, and switching
20:05 care providers is challenging. It is also a time when we lose data, which is important
20:11 if we are trying to get better long-term data. The idea is to provide continuity through
20:17 for those young people who are already in the service. If you are already over 18 when
20:24 you get referred, you would still get referred to existing services. You would not come through
20:31 that service. At the moment, it is specifically being set up to take people who have started
20:37 through when they were younger, to give continuity of clinical care and follow-up data.
20:46 Just to pick up on what you said about misrepresenting what was in this recommendation or other parts
20:53 of the report, you talked about a holistic assessment for young people and the whole
21:02 process. One of the comments we have is that the recommendation is based on dubious science.
21:12 I am just wondering whether you could solidify the advice or the recommendation that you
21:21 have put forward around a whole process for young people right up until the age of 25.
21:31 The bit that you think has been said to be based on dubious science is having a holistic
21:36 assessment.
21:37 It is about the wider recommendation about helping support young people right through
21:45 the whole process. The information that we have here says that it was based on dubious
21:54 science. I would be interested to hear whether that is one of the misrepresentations of the
22:01 report.
22:03 I think the misrepresentation was that we said that young people would not have to transition
22:11 at this vulnerable time, meaning transition between services. It was taken to mean that
22:21 they would not have to transition, meaning a gender transition at this vulnerable time.
22:28 That was a misreading because the term transition is used to describe the move from children's
22:34 to adult care as well as gender transition. It was taken to mean that we were saying that
22:39 children should not go through a gender transition at that time. That was not what we were saying.
22:47 I think it came under the heading about transition, a section-headed service transition. That
22:55 was a misreading. I do not know whether that helps.
22:58 It does help the power of the correct words.
23:03 I move to Sanders Gulhane.
23:09 Thank you, convener, and a creation of interest as a practising NHS GP. Thank you for joining
23:14 us, Dr Cass. I have grave concerns over the use of puberty blockers for children, given
23:19 the paucity of evidence and the early intervention study did not demonstrate benefit. I feel
23:26 that ideology and dogma have no place in medical treatment. Given that you stated that young
23:32 people's gender identity is fluid with no hierarchy, do you feel that there is a point
23:38 of age where it becomes more fixed?
23:42 There was a study released around the time that the report was in the press that showed
23:50 that gender discontentedness was relatively high from age 11 and it continued to drop
24:00 sequentially into early 20s. It is really difficult to know when exactly the sweet spot
24:09 is when somebody's gender identity is not going to be continuing to change and when
24:19 is the best time to commence an irreversible treatment. I think the thing that we were
24:26 quite struck by was young adults who we spoke to as part of the engagement process and also
24:35 through our qualitative research. They said that they wish they'd known there were more
24:39 ways to be trans than just a binary medical transition and you can be more fluid. You
24:47 don't necessarily have to go down a medical pathway, although some will. Their main advice
24:53 to their younger self would be it's not urgent, you don't have to rush, although they said
24:58 it feels urgent and their younger self probably wouldn't have taken too much notice of their
25:06 older self. That's the dilemma that we all face.
25:13 Certainly the things I believed when I was a child is very different to the things that
25:16 I believe now and what I feel is important. Your report states that we should be looking
25:23 to prescribe medication at 18, with your recommendation 6 stating that we need a trial. My question
25:33 is, if it is given below the age of 18, do you feel that there is a point where, or if
25:41 it's appropriate, this could happen without parents' knowledge, or do you feel that 18
25:48 is the point? Also, given your last statement, why did recommendation 8 say 18?
25:55 Largely because my remit doesn't extend beyond 18. As you know, a young person is considered
26:07 to have capacity at 16 unless we have good reason to think that they don't. It is hard
26:13 to make a legal distinction between a 16 and 18-year-old in terms of capacity. When I thought
26:22 about consent, the challenge is not so much about capacity but the other elements of it,
26:32 which is the clinical judgment to offer a treatment, which, as you know, we all bear
26:40 responsibility for treatments that we offer, and knowing whether that is the right treatment
26:46 for that individual, and secondly, the information that we give to inform consent about the risks
26:53 and benefits, which again is weak. So, you know, legal cases have obviously focused on
27:00 competence and capacity, but those are the other challenges, those other two pillars
27:07 of knowing whether we are giving the right treatment to the right people.
27:11 Certainly, Gillette competence can be from 13 onwards, and that's why I was asking about
27:18 parents as well. Do you feel that we should be able to use Gillette competence in this
27:26 treatment pathway, and if we can, should the parents be aware?
27:34 So the Tavistock avoided treating without parental consent and engagement, and everything
27:48 we know about outcomes in young people is that they thrive better with family support.
28:01 So I think, you know, I would have severe reservations about any child who was put on
28:09 this kind of pathway without a competent adult supporting that decision. And the Dutch protocol,
28:23 which the Tavistock was supposed to be adhering to in its service spec, specified parental
28:32 support for the decision, so I think that should stand.
28:38 Thank you. I have also got real concerns about private treatment. Your report, throughout
28:45 your report, you talk about an MDT approach, multidisciplinary team approach, and in fact
28:51 that is your recommendation nine. So should a single private practitioner be prescribing
28:59 medication, and is it appropriate for this to occur?
29:06 I have really deep concerns like you about private provision, by de facto based on the
29:14 recommendations we have made, that will not be meeting this standard. And I feel that
29:23 that does put young people at considerable risk to not have the level of assessment that
29:29 we're describing.
29:31 Thank you. My final question, if I may, Dr Kaur, is that regret and detransitioning is
29:35 an important area. What has your research shown, or has it been able to show, how many
29:46 children experience regret? And seeing as you've said that puberty blockers are irreversible,
29:53 what do we then do with children who do face that issue?
29:59 Okay, so the bit that's irreversible, that we know to be irreversible, is some of the
30:06 effects of the masculinizing and feminizing hormones. We don't know the percentage that
30:14 detransition or regret, and largely because the follow-up has not been long enough, and
30:25 also because those who do detransition or regret don't necessarily come back to the
30:31 NHS. And they frequently, sorry, excuse me, I don't know why I've got a frog in my throat
30:38 this morning. They often don't come back to the clinic that they originated from. So that
30:46 is a significant problem. But I think it's more subtle than that, because for example,
30:53 I spoke to a young adult who started transition very early, male to female. She's doing well.
31:05 She had puberty blockers at the earliest stage. She had masculinizing hormones at the earliest
31:13 stage, and she passes very well as a woman. But with hindsight, she knows she was a boy
31:19 with intense internalized homophobia and was gay. But at this point in her life, she's
31:26 clearly not going to detransition, so she wouldn't show up in regret or detransition
31:32 data, but thinks that maybe this was not the right decision to have made. So I mean, there
31:39 will be people who are living a good life, but may with hindsight have made a different
31:46 decision. And that's much, much more subtle. There are also people who are living their
31:53 best life having gone through a medical transition. And for them, the costs and side effects of
32:01 treatment are worthwhile compared to what it would have been like to have to live their
32:09 life within their birth register gender. So those sort of subtleties are really difficult
32:17 for us to get under the skin of.
32:19 Thank you.
32:20 Thank you. We'll move to Gillian Mackay.
32:23 Thanks, convener. And good morning, Dr Cass. Do you believe, and does your research show
32:28 that puberty blockers or gender-affirming hormones could be the right intervention for
32:32 some children or young people?
32:35 Yes, we think that certainly masculinizing and feminizing hormones could be the right
32:43 treatment. We don't know which young people those are. Puberty blockers, it's much less
32:52 clear what the indication is. I'm not sure whether the chair would like me to just say
32:59 something about what we do and don't know about puberty blockers and what the various
33:06 indications.
33:07 Yes, please.
33:08 Yeah. So the starting position as to why puberty blockers were introduced, because previously
33:20 you wouldn't start on a medical pathway until you were 16 plus. And this was because the
33:28 adult consultants who moved into the Dutch clinic had seen poor outcomes in adult patients
33:34 and felt that one of the reasons is that they weren't passing and that was having adverse
33:41 psychological effects. So she reasoned that if you blocked puberty from early, you wouldn't
33:47 get particularly the irreversible pubertal changes that birth-registered males get, where
33:55 you will get facial hair and drop your voice and so on. And that will always make it hard
34:00 for you to pass. And the second thing she reasoned was that it would buy time to think.
34:06 So going through those indications, there is no evidence that it buys time to think
34:12 and that the vast majority of those who go on to puberty blockers do then go on to masculinizing
34:18 and feminizing hormones. So it may be that it is altering the trajectory and making it
34:27 less likely that once you start, you will reconsider the options because you haven't
34:35 gone through your own puberty, you haven't gone through that psychosexual development
34:39 pathway. The other aspects that have been looked at is does it improve your body image?
34:46 Does it make you less dysphoric? And nobody, not even the original Dutch study, showed
34:52 that to be the case. And then the other thing is, does it improve your psychological well-being?
34:58 And although the original Dutch study found some weak evidence of that, the English study
35:05 did not replicate that and no other study has really replicated that. So that leaves
35:14 us with one specific indication that they may be helpful, particularly for birth registered
35:22 boys, birth registered males to prevent those irreversible changes. But one of the downsides
35:31 of this focus on puberty blockers, which have become almost totemic for being the way to
35:37 get on to a treatment pathway, is it stopped us looking at other ways of managing young
35:45 people's distress during that time when they're working out what the right pathway is for
35:51 them. And so we haven't looked at known evidence-based treatments for anxiety and depression, such
35:58 as psychological support or even medications for anxiety and depression that may be just
36:05 as effective or more effective than puberty blockers. I don't know if that all makes sense.
36:14 So it's been really clear about what they're for and for whom.
36:18 That's great, thank you. A range of trans organisations and people have said that the
36:23 report recommendations and the narrative surrounding it give the impression that transition would
36:28 be the worst outcome for a young person. How would you respond to those who get that impression
36:33 from the report? Yes, so for somebody who is going to have
36:40 an enduring long-term trans identity, medical transition is a really important option and
36:51 one from which many people do benefit. The risk of starting that transition at a time
37:02 when somebody is still developmentally labile, is still in the process of development, is
37:11 that you give the treatment to the wrong group of people. And the reason that is a negative
37:21 outcome is because medical transition does not come without costs in terms of effect
37:28 on sexual function, fertility, our knowns and unknowns about long-term bone health risk,
37:38 the limitations of surgery. All of those things are costs which are well worthwhile if you
37:46 have a long-term stable trans identity, but it's a high cost to pay if in the longer term
37:56 you don't. And so picking that sweet point where, as I said, where you have a high level
38:01 of certainty that you're giving the treatment to the right people is very important. And
38:07 the group that we have least understanding about is the group that we are most commonly
38:13 seeing now in clinic, which is birth registered females who are presenting in adolescence
38:22 for whom there may be a range of other factors driving their gender-related distress.
38:28 That's great, thank you. And just one final question. You mentioned earlier in other answers
38:34 about research. What does good research, in your view, look like in this area? And do
38:42 you think it's important that trans and non-binary people are involved in all stages in co-producing
38:48 that research?
38:51 So the answer to the second question is straightforward, yes, and that's clearly built into any research
39:02 and will be built into this. But we need well-designed studies with adequate follow-up and with really
39:13 clear comparisons with other kinds of treatment options. And that's what's been lacking from
39:27 previous research. So the team is thinking already about the most ethical and acceptable
39:37 ways to do that, and there will be very careful engagement with service users.
39:44 That's great, thanks, convener. Paul Smeeny.
39:48 Thank you, convener, and thank you to Dr Kefts for your contributions so far. I just wanted
39:53 to look at the wider balance of harms in this area. We've noted the average wait from referral
40:04 to seeing someone at a gender dysphoria clinic can often be over four years. In that time,
40:11 there may be significant distress—physical, psychological, social—and that may include
40:18 self-medicating with hormone replacement drugs. I'm not sure about puberty blockers and how
40:24 accessible they are. Obviously, that can introduce unregulated harms beyond, say, the practice
40:32 of bridging prescriptions. So I just wondered if you could maybe comment more on what observations
40:37 or what evidence you've been able to see about that broader practice or behaviour of self-medication.
40:42 Yes, I mean, we haven't had any way of systematically understanding how much that's going on, but
40:55 it's happening way more than we would wish. I think, as we all understand, the thing that
41:06 is driving this is major shortfalls in children's mental health services. So young people are
41:15 in a state of distress and anxiety. They are not getting any support for that or any other
41:22 aspects of their presenting problem often, and they only have available advice from the
41:31 internet or from peer support groups. So it's inevitable that they're going to take what
41:40 we would deem as higher-risk actions. I can understand that because they're often in a
41:51 situation where the care provided by the health system is failing them, and that's a system
41:57 failure that's related to workforce and all sorts of things. But I think there is another
42:04 big problem, which is fearfulness amongst healthcare practitioners. So these young people
42:11 are more disadvantaged than other similarly distressed young people, certainly in England,
42:17 because people have been bypassing them. Somebody comes and says they're gender questioning,
42:23 and health professionals feel nervous because they don't think they've got the skills. They're
42:27 worried about the toxicity of the debate. They're worried about doing or saying the
42:31 wrong thing. So they pass them straight through to the JIDS waiting list. And the areas that
42:39 they would have been able to manage because they've got all the skills to do so don't
42:43 get treated.
42:44 Do you have any thoughts about how best to remedy that?
42:51 I think it's starting already in the new centres in England, in that now that practitioners
43:02 have started seeing young people, they're really clear that these are the same young
43:06 people that they're seeing in other clinics, because there's been concern about starting
43:14 that new service. And I think it's about building confidence. I mean, when I was registrar for
43:21 the Royal College of Paediatrics and Child Health some 15 plus years ago, we were really
43:27 worried that we weren't going to be able to recruit paediatricians because they were so
43:31 scared about safeguarding. And you're in a situation where it was catastrophic if you
43:36 made an error in either direction, overdiagnosed or underdiagnosed. The research was poor,
43:42 there were no guidelines and there was very little training. And the way we remedied that
43:47 was with much better research, much better guidance and really clear training and supervision.
43:54 And that turns it round and it became an interesting area of practice. And that's what we want
43:58 to achieve here. A lot of it is about building confidence because professionals do have the
44:03 transferable skills and they just need to know that these are the same young people
44:08 with the same hopes and aspirations and anxieties as most of the rest of the people in their
44:14 clinic.
44:15 Can I just pick up on a point there, Dr Cass, in a response to Paul Sweeney, when he was
44:23 asking about unregulated access to hormonal treatment or to puberty blockers. Was I correct
44:31 in picking you up saying that it's happening way more than we would wish that children
44:36 and young people are accessing those medications in an unregulated way?
44:40 Yeah.
44:41 Okay, thank you. I just want it was for a point of clarity. Thank you. Ivan McKee.
44:47 I think I've covered all the issues on research follow-up and I did the earlier questions.
44:55 Thank you. Thank you, Dr Cass. I want to just explore, if you don't mind, a couple of questions
45:04 around the approaches to gender care in young people and the move, perhaps you described
45:11 it as the model, the dominant model of sort of gender affirming. You talked about clinicians
45:18 feeling pressure to simply affirm children and that that could lead to diagnostic overshadowing.
45:25 For example, you've touched on mental health issues and they've been missed. So I suppose
45:32 my first question is, how do you think a conversion therapy ban would affect that situation and
45:40 could you advise how we might go forward with that to ensure that we do give children that
45:48 protected time to look at this issue?
45:53 Yes, this one's a big challenge and all I can say is I'm glad I'm a doctor, not a litigator
46:00 because it is a really difficult problem. Everyone should be protected from conversion
46:09 therapy. It's a completely unacceptable practice. But the challenge of, because in thinking
46:18 about the legislation, the issue has been about intent and if a therapist engages with
46:26 a young person and they change their views about their gender identity during the course
46:33 of that therapeutic relationship and then they subsequently say it was because the therapist
46:43 had an intent to change their gender identity, that puts the therapist in a difficult position
46:51 because how can you legally determine intent and that anxiety, the anxiety that you may
47:02 be the test case is making clinicians even more anxious potentially about working in
47:11 this area and we don't want to do anything to frighten professionals off from working
47:17 in this. So walking that path is very difficult. I guess the only thing I would say is that
47:23 no credible professional body would support conversion therapy. So if any practitioner
47:33 is deemed to be practicing conversion therapy, it should in the first instance be a matter
47:38 for their professional regulator before it would be a legislative issue. But I don't
47:45 know how we get that balance right of protecting people from conversion therapy and not frightening
47:51 therapists who are just doing their job and may end up having an appropriate exploratory
47:56 conversation with a young person.
48:01 Thank you. That's helpful. It is one of the issues I think that on go me we do need to
48:07 get right for both the clinicians and the young people. Of course. I wonder if you could
48:12 just give us a little information. One of the things that has been of interest is about
48:16 the people presenting at the clinics who are same sex attracted and how we make sure that
48:22 we do have that space for those young people. You mentioned a case earlier on in the session
48:27 where someone perhaps did reflect on what had happened. And if I take it in context
48:33 of a conversion therapy bill, do you think that we need to take that apart and look at
48:41 a bill that deals with conversion therapy in terms of same sex attraction and trans
48:48 identity? Is that something we should consider?
48:53 I think we do need to. There are a very high percentage of these young people are same
48:58 sex attracted. And so you can you can see how the two things could get conflated. And
49:09 I guess this may have been naive, but one of the things that I was surprised about in
49:17 conducting this review is how much homophobia there still is, as well as transphobia. So
49:25 we do have to, you know, support people in being able to express their and understand
49:34 their sexuality as well as their gender identity.
49:40 Thank you. I have just one last question that has been raised with us, and it was around
49:48 including someone with trans identity in one of the reports that you and the review team.
49:55 Is that something you considered?
49:57 Sorry, say it again.
49:59 Why there was no trans people included in the review team?
50:04 Yes. So the the review team was very small. There were only four or five people. So whilst
50:12 you know, we weren't specifically excluding trans people from the review team, but we
50:16 didn't have anyone who applied. But we had I mean, in a way, I think it's hard for a
50:26 person on a team to be a sort of tokenistic anyway, reset representative of the whole
50:34 community. What we did ensure is that we had a very wide engagement. So we spoke every
50:43 four to six weeks to the the main trans advocacy groups. We had we had listening sessions.
50:55 We had with with service users, we had 18 focus groups with young people. We had been
51:04 around tables with the the support and advocacy groups. We had qualitative research that took
51:13 account of both young people and young adults experiences. And and we also consulted internationally.
51:27 And so we made every effort to incorporate service users voices as broadly as we could.
51:36 That's really helpful. Thank you very much.
51:39 Ruth Maguire.
51:41 Thank you, convener. Dr Cass, I wonder if I could just go back a little. You spoke about
51:46 fearfulness of professionals in discussing this area. And then in answer to my colleague
51:55 Carol Mochan around the issues of conversion and professionals having space to explore
52:02 options with children and young people. You said research, guidance, training and supervision
52:10 were the answers. Is there is there anything further? I mean, I know you'll have had personal
52:15 experience of the heat and noise that surrounds this this topic. And I just wondered if you
52:22 had anything further to add on that.
52:25 Yes, I think I think one of the things that was challenging for the Tavistock and the
52:32 JID service is that they were a single provider. And any time when you have a single provider
52:40 and you don't have peer review, you don't have the ability to share practice with other
52:46 centres that makes it makes it very difficult. And that's why the way we're setting things
52:53 up in England is that there's a single national provider collaborative where those centres
53:00 can come together to as an overarching structure to support all of the regional centres. And
53:07 the idea is that it doesn't matter whether you walk into a service in Birmingham or London
53:13 or Newcastle, whatever, you will get the same standards of care, the same decision making.
53:19 And that means you have, you know, shared clinical guidance, you have shared training,
53:25 the research works across and really importantly, that you share data, you have a shared data
53:32 set that works across all those centres. And that was why I said that if you know there
53:38 was interest from Scotland that your centre became a regional centre, you know, although
53:46 it might not be physical, I can't speak for NHS England or the formal governance or any
53:52 of that, but being able to share practice, I'm sure is something that, you know, would
53:57 probably be welcome on both sides.
54:00 Okay, thank you. Sandesh Gohani.
54:03 Thank you, convener. Dr Cass, I know that adult services was outside of your scope,
54:09 but you did mention them. And in point 1931, you stated that there was an expectation that
54:15 patients would be started on masculinising, feminising hormones by their second appointment,
54:20 which was a concern given the complexity of presentations. Did your research show anything
54:25 similar with children's services?
54:30 We there, I know that in the past, there have been children and young people who have started
54:38 on treatment relatively quickly. There was variability between the different, you know,
54:46 the different teams within the JID service. But that was certainly not supposed to be
54:55 the way in which things operated. And I think certainly latterly, there was more careful
55:01 control to make sure that that didn't happen. Just in terms of that comment about the adult
55:07 services, I had a number of people with concerns from adult services who spoke to me and that
55:15 was their feedback to me. And given that these, they were seeing the same sorts of young people,
55:24 you know, moving through who had that same complexity of presentation, they had clinical
55:30 concerns about having to make those decisions so quickly.
55:36 Good morning, Dr Cass. I just want to pick up on a couple of areas that have already
55:45 been discussed. Firstly, about the cohort of patients. So obviously, the data is showing
55:52 a huge and a very fast increase in birth-registered females, the majority of whom are same-sex
55:59 attracted. And this is a very different cohort from that looked at by the earlier studies.
56:06 And the new cohort as well has a much more complexity of presentation. So you've suggested
56:12 that care should routinely include, for instance, things like screening for neurodevelopmental
56:17 conditions. I'm wondering if you can tell us a little bit more about this, the change
56:22 in the cohort, the extent to which treatments had been based on the previous cohort and
56:27 what risks there might be around that.
56:29 Yeah, well, you've summarised it exactly. If you take, as I said, the research is already
56:38 weak on the previous cohort and even more limited on this current cohort. So you can't
56:46 make any assumptions that the original puberty blocker studies do read across to this group.
56:58 And I think it's important that we consider this newer presenting group in the broader
57:06 context of what's happening to adolescents in Gen Z more widely. So we know that there
57:14 are very high rates of depression and anxiety. There are stresses that previous generations
57:22 didn't have growing up in terms of social media and expectations on young people that
57:31 arise from that early exposure to pornography. And we don't understand what any of those
57:38 do to how you might present your distress. And certainly for some young people, that
57:47 distress or feeling that you don't fit what you perceive to be the expected gender norms
57:59 may manifest through questioning your gender identity. And that's why we really have to
58:07 take this as a new cohort, not rely on previous research and try and work with young people
58:15 to help them unpick all of those things that may have led to that gender distress. I think
58:22 one of the things that's been somewhat lost in the debate is that there's a really close
58:27 mind-body interaction in that interaction between mental health and how you physically
58:34 manifest it. And unpacking that is really complex and difficult and has to be done very
58:41 carefully.
58:42 Thank you. And just on de-transitioners, if I may, we need to close on—I'm afraid we
58:47 need to finish by 10 o'clock this session. Can I thank you, Dr Cass, for your attendance
58:52 today and for the information that you've given the committee? I'm sure it'll help us
58:57 in our further inquiries as we have other interested parties coming along to speak with
59:04 us in the coming weeks. So thank you for your time. And I now suspend this meeting.
59:09 [BLANK_AUDIO]