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The Cass Review: Independent review of gender services for children and young people



The findings of the final Cass review come as no surprise to those of us who have been following gender healthcare over recent years.  Cass reports that gender-dysphoric children have been let down by services that built their interventions on a weak evidence base, and that used medical approaches to try to solve what were often psychological issues.  She notes the toxic atmosphere that resulted in clinicians being afraid to discuss transgender healthcare, and she identifies the dangerous blurring of boundaries between clinicians and activists at the former Tavistock Clinic.  


The Cass review, of course, has no direct implications for services in Scotland.  Cass was commissioned by NHS England to provide a review of English services.  But Scottish politicians and health service, education and social service leaders would be foolish to ignore its findings.  And yet…


  • Whilst in England there are plans to close the two clinics that catered for gender-dysphoric children and young people, and to replace them with closer-to-home services with more evidence-based underpinnings, there are no plans to do so in Scotland.

  • Whilst Cass has suggested a root-and-branch structural reform of gender services in England, here in Scotland the most recent draft standards for gender services seem to suggest a doubling down on the existing model, with many of the mistakes that Cass identified in English services being repeated here in Scotland.  For example, the Scottish draft standards state that 3rd sector organisations will have a role in the planning, delivery and evaluation of NHS gender services.  This is surprising:  the close and detrimental involvement of the trans activist charity Mermaids in the development of services at the Tavistock has been discussed at length by former Newsnight journalist, Hannah Barnes (Time To Think).  Why should we suppose that Scottish NHS services would be invulnerable to undue influence from 3rd sector organisations?

  • While Cass in her interim report raised the importance of schools and that that social transitioning was ill-advised, Scottish Education ignored all the concerns raised regarding the continued existence and implementation  of the guidance for schools, Supporting Transgender Pupils in Schools. It continued to promote the Relationships Sexual Health and Parenting resource in the school curriculum (RSHP) which has gender ideology woven throughout it, and it continued to support and finance third sector lobby groups such as LGBTYS which have a direct impact and influence on schools. 

  • Whilst Cass has ruled out the prescription of puberty blockers unless they are prescribed within a research trial, no such change in practice seems to be on the horizon in Scotland.  This is despite the almost complete lack of evidence on the effects of puberty blockers on adolescent brain development.  

  • The proposed Scottish conversion practices legislation, whilst well intentioned, includes the transgender population in its remit.  Cass suggests that the default approach to gender dysphoria in children and young people should be counselling.  It is hard to imagine that therapists in Scotland will be keen to work with gender-dysphoric children and young people, when they have reason to fear that that work could result in investigation and prosecution under the vaguely-worded conversion practices law. There is also a need for leaders to develop a holistic, preventative approach starting with schools and a rethink about what multiagency assessment and intervention really means.


Time was when Scottish politicians and healthcare leaders could have reasonably plead ignorance to the failings of the affirmative medical model.  That time has passed.  The affirmative-medical approach to gender dysphoria appeared at first to be progressive and enlightened but it is now turning into an unfolding medical scandal.  Our elected leaders and healthcare specialists can no longer hide behind a wall of silence.  


Scotland should either take on board the findings of Cass, or commission its own review of services.  Health Improvement Scotland alongside other agencies such as education and social work, that represent all aspects of the fact that much of this issue is a cultural one need to conduct such a review, and we shall be writing to them to suggest that they do.  It cannot be beyond the wit of politicians and health experts to devise a model of care that is not only enlightened and progressive, but also safe and evidence-based.  This is all that we ask.


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