<https://cass.independent-review.uk/home/publications/final-report/>

'Dr Hilary Cass has submitted her final report and recommendations to
NHS England in her role as Chair of the Independent Review of gender
identity services for children and young people.

The Review was commissioned by NHS England to make recommendations on
how to improve NHS gender identity services, and ensure that children
and young people who are questioning their gender identity or
experiencing gender dysphoria receive a high standard of care, that
meets their needs, is safe, holistic and effective.

The report describes what is known about the young people who are
seeking NHS support around their gender identity and sets out the
recommended clinical approach to care and support they should expect,
the interventions that should be available, and how services should be
organised across the country.

It also makes recommendations on the quality improvement and research
infrastructure required to ensure that the evidence base underpinning
care is strengthened.

In making her recommendations, Dr Cass has had to rely on the currently
available evidence and think about how the NHS can respond safely,
effectively, and compassionately, leaving some issues for wider societal
debate.

Download the Final Report
(NB to open the report in browser, right click and select ‘open in new
tab’)

The peer-reviewed systematic evidence reviews that informed the report
and recommendations are available here.

We have received questions about the report’s findings and
recommendations, including those raised by members of the public and
other stakeholders. We have collated as many of those questions as we
can in a series of FAQs.

Context
Exploration of identity is a completely natural process during childhood
and adolescence and rarely requires clinical input. However, over the
past five – ten years the number of children and young people being
referred for NHS support around their gender identity has increased
rapidly.

As a result, young people are waiting several years to receive clinical
support and during this time they and their families are left to make
sense of their individual situations, often dealing with considerable
challenges and upheaval.

There has been a similar pattern in other Western countries, with
clinicians noting not only the rising number but also a change in the
case mix of the young people seeking support.

There have been many more birth-registered females being referred in
adolescence, marking a shift from the cohort that these services have
traditionally seen; that is, birth-registered males presenting in
childhood, on whom the previous clinical approach to care was based.

Clinicians also noted that these young people often had other issues
that they were having to manage alongside their gender-related distress.

The Independent Review set out to understand the reasons for the growth
in referrals and the change in case-mix, and to identify the clinical
approach and service model that would best serve this population.

To provide an evidence base upon which to make its recommendations, the
Review commissioned the University of York to conduct a series of
independent systematic reviews of existing evidence and new qualitative
and quantitative research to build on the evidence base.

Dr Cass also conducted an extensive programme of engagement with young
people, parents, clinicians and other associated professionals.

Overview of key findings
There is no simple explanation for the increase in the numbers of
predominantly young people and young adults who have a trans or gender
diverse identity, but there is broad agreement that it is a result of a
complex interplay between biological, psychological and social factors.
This balance of factors will be different in each individual.
There are conflicting views about the clinical approach, with
expectations of care at times being far from usual clinical practice.
This has made some clinicians fearful of working with gender-questioning
young people, despite their presentation being similar to many children
and young people presenting to other NHS services.
An appraisal of international guidelines for care and treatment of
children and young people with gender incongruence found that that no
single guideline could be applied in its entirety to the NHS in England.
While a considerable amount of research has been published in this
field, systematic evidence reviews demonstrated the poor quality of the
published studies, meaning there is not a reliable evidence base upon
which to make clinical decisions, or for children and their families to
make informed choices.
The strengths and weaknesses of the evidence base on the care of
children and young people are often misrepresented and overstated, both
in scientific publications and social debate.
The controversy surrounding the use of medical treatments has taken
focus away from what the individualised care and treatment is intended
to achieve for individuals seeking support from NHS gender services.
The rationale for early puberty suppression remains unclear, with weak
evidence regarding the impact on gender dysphoria, mental or
psychosocial health. The effect on cognitive and psychosexual
development remains unknown.
The use of masculinising / feminising hormones in those under the age of
18 also presents many unknowns, despite their longstanding use in the
adult transgender population. The lack of long-term follow-up data on
those commencing treatment at an earlier age means we have inadequate
information about the range of outcomes for this group.
Clinicians are unable to determine with any certainty which children and
young people will go on to have an enduring trans identity.
For the majority of young people, a medical pathway may not be the best
way to manage their gender-related distress. For those young people for
whom a medical pathway is clinically indicated, it is not enough to
provide this without also addressing wider mental health and/or
psychosocially challenging problems.
Innovation is important if medicine is to move forward, but there must
be a proportionate level of monitoring, oversight and regulation that
does not stifle progress, while preventing creep of unproven approaches
into clinical practice. Innovation must draw from and contribute to the
evidence base.
Overview of Recommendations
The recommendations set out a different approach to healthcare, more
closely aligned with usual NHS clinical practice that considers the
young person holistically and not solely in terms of their
gender-related distress. The central aim of assessment should be to help
young people to thrive and achieve their life goals.

Services must operate to the same standards as other services seeing
children and young people with complex presentations and/or additional
risk factors.
Expand capacity through a distributed service model, based in paediatric
services and with stronger links between secondary and specialist
services.
Children/ young people referred to NHS gender services must receive a
holistic assessment of their needs to inform an individualised care
plan. This should include screening for neurodevelopmental conditions,
including autism spectrum disorder, and a mental health assessment.
Standard evidence based psychological and psychopharmacological
treatment approaches should be used to support the management of the
associated distress from gender incongruence and cooccurring conditions,
including support for parents/carers and siblings as appropriate.
Services should establish a separate pathway for pre-pubertal children
and their families. ensuring that they are prioritised for early
discussion about how parents can best support their child in a balanced
and non-judgemental way. When families/carers are making decisions about
social transition of pre-pubertal children, services should ensure that
they can be seen as early as possible by a clinical professional with
relevant experience.
NHS England should ensure that each Regional Centre has a follow-through
service for 17–25-year-olds; either by extending the range of the
regional children and young people’s service or through linked services,
to ensure continuity of care and support at a potentially vulnerable
stage in their journey.  This will also allow clinical, and research
follow up data to be collected.
There needs to be provision for people considering detransition,
recognising that they may not wish to re-engage with the services whose
care they were previously under.
A full programme of research should be established to look at the
characteristics, interventions and outcomes of every young person
presenting to the NHS gender services.
The puberty blocker trial previously announced by NHS England should be
part of a programme of research which also evaluates outcomes of
psychosocial interventions and masculinising/ feminising hormones.
The option to provide masculinising/feminising hormones from age 16 is
available, but the Review recommends extreme caution. There should be a
clear clinical rationale for providing hormones at this stage rather
than waiting until an individual reaches 18. Every case considered for
medical treatment should be discussed at a national Multi- Disciplinary
Team (MDT).
Implications of private healthcare on any future requests to the NHS for
treatment, monitoring and/or involvement in research, and the dispensing
responsibilities of pharmacists of private prescriptions needs to be
clearly communicated.'