A comprehensive review of NHS support for children experiencing gender-related distress was needed, and we welcome the fact the Cass Review team took on this task. The report acknowledges, and we agree, that the NHS has been failing trans children by not providing the timely and holistic support that all children deserve.

We appreciate having the opportunity for trans young people from The Kite Trust to have a voice as part of the review. Through the focus groups we held and participated in, trans children and young people from Cambridgeshire and Peterborough said that we want to see:

• Services staffed by people who are trained in working with trans young people, who listen to us and support us to make informed choices about our care.
• Better communication and information provided by services about the care available and keeping in touch whilst waiting.
• Access to wider forms of gender-affirming care including voice coaching, hair removal and mental health support.
• Easier access to care closer to where we live, reducing long and costly journeys to clinics, and shorter waiting times.

Initially, we feel that many of these views have been considered within the recommendations made and thank Dr Cass for listening to those of us who are impacted most – trans children and their families. However, we ask that the NHS commissioners continue to engage with trans people in co-designing the new services based on these recommendations – as is accepted best practice for NHS services generally.

We know that there will be many different outlets reporting (or misreporting) elements of what the report contains over the coming days in ways that may cause concern and distress. At this moment, we think our trans community and allies should particularly hear what Dr Cass herself has said in the opening of the report:

“The central aim of gender care should be to help young people to thrive and achieve their life goals. The immediate goal must be to address distress and any barriers to participation in everyday life.”

“You must have the same standards of care as everyone else in the NHS”

“I am asking you to join any research studies that look at the longer-term outcomes of these interventions so you can help all those

coming behind you. We have to show that the treatments are safe and produce the positive outcomes you want from them.”

“I know you need more than medical intervention, but services are really stretched, and you are not getting the wider support you need in managing any mental health problems, arranging fertility preservation, getting help

with any challenges relating to neurodiversity, or even getting counselling to work through questions and issues you may have. We need to look at all the elements that are needed in a package of care that will help you thrive and fulfil your broader life goals.”

“The first step for the NHS is to expand capacity, offer wider interventions, upskill the broader workforce, take an individualised, personal approach to care, and put in place the mechanisms to collect the data needed for

quality improvement and research.”

“I know there are many who have waited too long already and will continue to do so, and that like me, colleagues across the NHS are deeply concerned about this. We can’t fix everything overnight, but we must make a start.”

We will continue to review the report in depth over the coming days and weeks and there have been some initial responses to the report from NHS England that we want to understand further before being able to pass on factual information to our wider community.

Our youth work team remains available to any young people and family members who would like support at this time – please email [email protected].

Update: 18th April 2024

On the 17th April, The Kite Trust and other LGBTQ+ support organisations met with Dr Hilary Cass and her team to get answers to the questions raised by trans young people and their families in the wake of the report release.

Download a copy of the Q&A here.

Are all the recommendations made in the Cass Review Report now in effect straight away? 

No. The Cass Review Report made recommendations to NHS England. NHS England is now responsible for reviewing them and deciding if, how, and when aspects would come into effect.  

Is the Cass Review Report advocating for all trans healthcare for 18-25 year olds to be stopped? Is the Cass Review Report saying that trans people would be better off if they didn’t transition?  

The Cass Review Report made a recommendation for a follow through service for 17-25 year olds connected to the children’s service because there have been issues with individuals having gaps in their care when being transferred between children and adult services at the age of 17. The word ‘transition’ was used in the report to mean a transition between NHS services and not in reference to gender transition.  

Dr. Cass feels this is important that young people get a continuity of care and that they are properly supported, potentially by seeing the same doctors, nurses and other specialists beyond the age of 17. Anyone referred for the first time aged 18 or over would be directed straight to an adult service, as is currently the case, and the proposal would also allow those who were first seen as children to move to opt into moving to an adult service when they wanted to do so.  

It is outside of the remit of the Cass Review to say anything about the prescription of gender affirming hormones from the age of 18 onwards and there are no recommendations made around this matter in the report. 

If the 18-25 follow-through system were to come into being, what would it look like? 

Dr. Cass would like to see trans people never having a gap in care between children’s and adults’ services – which has been too often the case previously. As such, the recommendation is for there to be two streams of care provided for 18-25 year olds. The first would offer continuity of care for those who have been patients of a children’s service and the second would be a route for direct referral into adult services as is currently the case.  

It is noted that the period around transferring from children’s to adults’ services has correlated with high risks around mental health and wellbeing, and an aim of the follow-on service is to address this and ensure support is available. The service is envisioned as a new provision to further expand the capacity and access to gender affirming healthcare for 18-25 year olds.  

Is Dr. Cass against a ban on conversion therapy? 

Dr. Cass has stated that there should be zero tolerance for conversion practices and it should be a matter for a regulator to investigate if anyone is found to be causing harm in this way. Dr. Cass is keen for legislators to enact a ban on conversion practices, and that this ban should come with enough support for NHS staff to understand the difference between conversion practice and supporting young people who are yet fully certain about their gender identity. 

Does Dr. Cass believe puberty blockers are unsafe drugs? If so, why is OK for them to be prescribed to cis kids and not trans kids? 

The Cass Review Report does not conclude that puberty suppressing hormones are an unsafe treatment. The report supports a research study being implemented to allow pre-pubertal children to have a pathway to accessing this treatment in a timely way and with suitable follow up and data collection, to provide the highest quality of evidence for the ongoing use of puberty suppressing hormones as a treatment for gender dysphoria.  

In the data the Cass Review examined, the most common age that trans young people were being initially prescribed puberty suppressing hormones was 15. Dr. Cass’s view is that this is too late to have the intended benefits of supressing the effects of puberty and was caused by the previous NHS policy of requiring a trans young person to be on puberty suppressing hormones for a year before accessing gender affirming hormones. The Cass Review Report recommends that a different approach is needed, with puberty suppressing hormones and gender affirming hormones being available to young people at different ages and developmental stages alongside a wider range of gender affirming healthcare based on individual need.  

Is the Cass Review Report saying that being trans can be caused by neurodiversity, mental health conditions, or traumatic experiences?  

No. Dr. Cass believes that all people should get all of their care needs addressed, and that includes trans people. The Cass Review Report includes recommendations around support for neurodiversity, mental health and the effects of childhood trauma because previously trans people have been denied the same support as their cisgender peers and an expectation has been set that all of their care should be provided through gender services.  

Dr. Cass is keen to see a cross-over of professionals involved in the new children’s gender services, including those with expertise in neurodiversity, to best support the patients of these services and service users. Dr. Cass has stated that mental health needs (including depression, anxiety, and eating disorders) should be addressed with the same evidence-based interventions for all children, regardless of whether they are trans or cis.  

Why were 100 out of the 102 studies on puberty blockers and hormones rejected? Could you explain the Newcastle-Ottawa scale, and why you chose this scale above all others, outside of its use in the 2020 UoY study cited in 14.19? Would it not be wise to have used a scale that didn’t prioritise randomised control trials, since double-blinding using hormone treatments is impossible? 

Randomised Control Trials (RCTs) are considered to be the highest form of evidence in medicine, but not the only marker of quality for a study. Dr. Cass agrees that it is inappropriate and not possible to conduct a ‘double-blind’ study (where participants in the study do not know whether or not they are receiving treatment) in this instance.  

Within the evidence considered, Dr Cass stated that there were hardly any RCTs in the existing studies, and that study type was not the main factor in deciding whether studies were included. Factors around the size of the study as well as the period and extent of follow-up were part of the decision-making process on rating the quality of the evidence.  

The Cass Review Report took evidence from studies that were deemed medium quality as well as from the two that were deemed high quality. Dr. Cass stated that many of these studies didn’t necessarily provide evidence for what they needed them to look at – particularly the psychological impacts over an extended period of time. 

Dr. Cass feels that the NHS now has a challenge to build trust from trans young people and asks those who are of the right age to get involved in studies on gender affirming treatments to ensure that we have the highest quality of evidence going forwards. Dr. Cass wants the community to be involved in designing high quality studies and for the new children’s gender services to have the research infrastructure to deliver these.  

What was the motivation behind Dr. Cass’s meeting with Patrick Hunter, architect of Florida’s anti-trans SB 254 bill in 2022? Did this inform the report? 

Patrick Hunter approached the Cass Review stating he was a paediatrician who had worked in this area. The Cass Review team were not aware of his wider connections and political affiliations at this time and so he met the criteria for clinicians who were offered an initial meeting. This initial contact was the same as any paediatrician who approached the study. The Cass Review team declined any further contact with Patrick Hunter after this meeting.  Patrick Hunter and his political connections has had no influence on the content of the Cass Review Report.