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BPS updates, Sex and gender

'…young people caught in the middle of a stormy social discourse…'

Ella Rhodes reports as the British Psychological Society respond to the Cass Review.

19 April 2024

The British Psychological Society has commended the final report from Dr Hilary Cass's review into gender identity services for children and young people, and supported its recommendations on expanding service capacity. The BPS acknowledged the importance of psychological therapies in gender services and also agreed with the report that better evidence was needed to assess the effectiveness of psychological interventions in supporting children and young people. 

The Cass Review was commissioned by NHS England following criticisms of long waiting lists and the care provided by the Gender Identity Development Service (Gids) based within London's Tavistock and Portman NHS Trust. Gids, which closed in March this year following an interim report from the Cass Review, was the only NHS gender identity service for children and young people in England and Wales and has since been replaced by two regional children and young people's gender services in the North West and London. 

In her foreword Cass, former President of the Royal College of Paediatrics and Child Health and an honorary Consultant Paediatrician at Evelina London Children's Hospital, wrote openly about the criticism she had received in carrying out the review. She added that there were few other areas of healthcare where professionals were so afraid to openly discuss their views, and where name-calling and vilification on social media echoed 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.' 

The review explored the increase in children and young people with a trans or gender diverse identity, the clinical approach used with children and young people questioning their gender, the evidence base for treatments and the use of puberty blockers. Among more than 30 recommendations, Cass suggested a different approach to treatment which would consider young people holistically – rather than solely focusing on distress related to gender.

The review involved engagement with individuals with lived experience, clinicians and organisations working with LGBTQ+ children and young people. Cass held weekly listening sessions with people who identified as transgender, non-binary and gender as well as those who had questioned their gender. Parents and carers of children and young people who had questioned their gender were also involved in these listening sessions and clinicians who had directly worked with children and young people.

The review also used focus groups to hear from young people and adults aged between 14 and 30 with lived experience. Some of these were carried out by six support and advocacy organisations on behalf of the review.  

Academics at the University of York carried out research for the Cass Review on the use of puberty blockers as well as hormonal treatments. The report pointed out that puberty blockers were initially used with the intention that they may give young people space to consider their gender prior to puberty starting. 

The University of York's systematic review found that the use of puberty blockers did not impact gender dysphoria or body satisfaction. It also found 'insufficient/inconsistent' evidence on the effects of suppressing puberty on psychological wellbeing, cognitive development, cardio metabolic risk and fertility. 

'Given that the vast majority of young people started on puberty blockers proceed from puberty blockers to masculinising/feminising hormones, there is no evidence that puberty blockers buy time to think, and some concern that they may change the trajectory of psychosexual and gender identity development.'

The review wrote a letter to NHS England in July last year advising that puberty blockers only have benefits in certain narrow circumstances and pose potential risks to neurocognitive and psychosexual development, and bone health, and they should only be offered as part of a research protocol. NHS England has since published a new clinical policy on using puberty blockers following public consultation. 

Responding to the Cass report BPS President Elect Dr Roman Raczka said the BPS wanted to commend Dr Hilary Cass's thorough and sensitive review into an area which was highly complex and controversial to many. 'All too often, the way this controversy has played out in public has been damaging to the very children, young people and families desperately seeking help. We wholeheartedly join Dr Cass's call for an end to the deeply concerning, public bullying and vilification of professionals working in this challenging area.

'The prescribing of puberty blockers has received a great deal of focus both in wider discussions about gender, and within the report itself. We agree with Dr Cass that the controversy around this issue has sometimes taken focus away from the important role of psychological interventions in gender services to support young people and their families. We agree that it's vital to create a sound evidence base and better understanding of the long-term effects of puberty blockers and the need for more data in this area to help young people make informed decisions about their treatment and to support the clinicians providing care and treatment.'

On 21 May, a group of '16 senior clinical psychologists' had a letter published in The Observer, headlined 'We are ashamed of the role psychology played in gender care'. Calling what happened at Gids 'a multi-factorial systemic failure', the psychologists noted that 'These were psychology-led services. Whether intentionally or not, and many were doing their best in an impossible situation, it was clinical psychologists who promoted an ideology that was almost impossible to challenge; who, as the Cass report found, largely failed to carry out proper assessments of troubled young people, and thus put many on an "irreversible medical pathway" that in most cases was inappropriate; and who failed in their most basic duty to keep proper records.' They go on criticise the BPS for a failure to 'produce guidelines for clinicians working with young people in this complex area', and for an official response which 'now minimises its own role in events and calls for "more psychology" as the answer.'

Cass has also spoken further with the media, describing clinics' failure to share data as 'co-ordinated' and 'ideologically driven'. She talked about the 'pretty aggressive' response and 'childish' debate, saying she was particularly concerned about misinformation, adding: 'If you deliberately try to undermine a report that has looked at the evidence of children's healthcare, then that's unforgivable. You are putting children at risk by doing that.'