For most people their gender identity is the same as their sex at birth. But for a small but growing number of children and adolescents it is not. How to treat, clinically, this vulnerable group has become unfortunately a toxic and polarised debate in medicine and in broader society. Empathy and compassion are in short supply. But they are needed to care for young people looking for support from NHS England in relation to their gender identity.
That is why the sober and sensitive review of English health service practice by Hilary Cass, a former president of the Royal College of Paediatrics and Child Health, was necessary and important. In her 398-page report she found no “reliable” evidence that the benefits of drug treatments for children who identify as transgender outweighed their harms. It is welcome news that the current “medical pathway” in England will be revised in the light of its shortcomings.
Some changes are already under way, sparked in part by Dr Cass’s interim report. England’s NHS has found itself unable to cope with a surge of trans identification over the last decade, especially among biological girls. This had led to excruciatingly long waiting times for treatments. The dramatic change in the patient profile of young people presenting with gender distress, argues the final review, should be reflected by adopting a new approach to patients. This ought to be welcomed as a realistic response to a distinctly modern phenomenon.
Dr Cass advocates moving away from supporting children with gender dysphoria with puberty blockers and cross sex hormones to providing therapy to “alleviate their distress”. Her belief rests on making a connection between the rise in girls experiencing a mental health crisis and the rise of girls developing gender-related distress. Such an assumption lays Dr Cass open to the charge that her suggestions are tantamount to talking people out of their desired gender change. However, she disputes that her intent is to “change the person’s perception of who they are”. The report’s credibility will be significantly undermined if that objective is not met.
This review is not a full stop in the debate, but part of a continuing conversation. Adopting a precautionary outlook seems prudent when dealing with life-changing treatments for young people when the long-term effects remain poorly understood. Trans advocates agree with Dr Cass that waits should be shorter and better mental health care provision is needed, and approve of her call for more local services. They, like her, accept that there will “be a small number of young people for whom a medical pathway is the right pathway”. But before giving young people drugs, Dr Cass asks NHS medics to consider alternative interventions, especially for those with “existing mental health problems and neurodiversity”. That seems uncontroversial, though the numbers waiting for mental health treatments dwarf those in gender-affirming care.
Some practitioners prefer the old system and will resist the new approach. This hinders an already complex process of designing and commissioning a new care model, and recruiting and training NHS staff. Ministerial support will be essential to implement Cass’s recommendations. Otherwise the current lengthy waits for transgender services will grow, sending more patients to private doctors to obtain the puberty blockers that the NHS has ceased prescribing.
No one is sure why the number of children who identify as transgender has grown exponentially. Many people were disoriented by the sudden simultaneous rise of trans identity in wealthier nations. Some fell back on prejudice to cope with their confusion. This is fertile territory for Trumpian cruelty, resulting in a number of American states banning transgender care for adolescents. In Britain, some MPs have also attempted to stir up hatred towards the trans community to win votes. It may be too much to ask for politicians in an election year to curate sympathetic and understanding conversations about this issue, but they should.
