What is the Cass Review interim report?
The Cass Review is an Independent Review of Gender Identity Services for Children and Young People. It was ‘commissioned by NHS England and NHS Improvement in Autumn 2020 to make recommendations about the services provided by the NHS to children and young people who are questioning their gender identity or experiencing gender incongruence .’ In March 2022, the Cass Review submitted an interim report to NHS England. This interim report ‘[set] out [the] work to date, what [had] been learnt so far and the approach going forward .’
Why is the Cass Review relevant to school staff?
The interim report states that the care of children with gender-related distress is ‘everyone’s business’ (p. 7) . It acknowledges ‘the important role of schools and the challenges they face in responding appropriately to gender-questioning children and young people’ (para. 4.14). Although the interim report does not explore the role of schools, it states that schools are one of the issues that ‘will be considered further during the lifetime of the Review’.
This guide to the Cass Review interim report is not a summary of the report. It simply highlights sections of the report that may be relevant to teachers, and links this information to teachers’ duties and responsibilities. A summary and full version of the Cass Review interim report can be found online .
The United Kingdom has seen a significant increase in the number of children seeking help for distress in relation to their biological sex. Many school staff first started noticing the phenomenon of children – predominantly teenaged girls – wanting to change sex during the last decade.
In recent years, there has been a significant increase in the number of referrals to the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust (para. 1.1).
From a baseline of approximately 50 referrals per annum in 2009, there was a steep increase from 2014-15, and at the time of the CQC inspection of the Tavistock and Portman NHS Foundation Trust in October 2020 there were 2,500 children and young people being referred per annum, 4,600 children and young people on the waiting list, and a waiting time of over two years to first appointment (para 3.10).
This surge in children seeking help for distress in relation to their sex is occurring in the context of an ongoing public debate around issues relating to sex, gender and gender identity.
Over the last few years, broader discussions about transgender issues have been played out in public, with discussions becoming increasingly polarised and adversarial. This polarisation is such that it undermines safe debate and creates difficulties in building consensus (para. 2.4).
This being a new phenomenon, research is limited and no consensus exists (within the scientific community) about possible causes and most appropriate treatment options.
At primary, secondary and specialist level, there is a lack of agreement, and in many instances a lack of open discussion, about the extent to which gender incongruence in childhood and adolescence can be an inherent and immutable phenomenon for which transition is the best option for the individual (para. 1.7).
Teachers carry out their professional duties in accordance with existing legislation, statutory and non-statutory guidance, and professional standards. Not only must teachers secure a balanced treatment of political issues, they must take a child-centred, evidence-based approach, and take care not to express personal beliefs in ways which could exploit pupils’ vulnerabilities. Teachers may not, for example, present, as fact, childhood gender incongruence as an inherent and immutable phenomenon as this is a contested idea rather than an established evidence-based fact.
Low quality evidence
The Cass Review interim report acknowledges that ‘[over] the last few years, broader discussions about transgender issues have been played out in public, with discussions becoming increasingly polarised and adversarial’ (para. 2.4). Many educators may feel confused or conflicted about approaching the issues of sex and gender identity within school. The above-mentioned rise in referrals to GIDS has been accompanied by an increasing number of news reports claiming that some teachers and/or schools are promoting the idea that gender identity supersedes sex. However, there is insufficient high quality, longitudinal data (relating to gender-questioning children) from which to draw robust conclusions. There is a notable gap in the evidence base pertaining to the surge in female teenagers seeking support from gender identity services.
Aspects of the literature are open to interpretation in multiple ways, and there is a risk that some authors interpret their data from a particular ideological and/or theoretical standpoint (para. 1.29).
Decisions need to be informed by long-term data on the range of outcomes, from satisfaction with transition, through a range of positive and negative mental health outcomes, through to regret and/or a decision to detransition. The NICE evidence review demonstrates the poor quality of these data, both nationally and internationally (para. 3.21).
It is also important to note that any data that are available do not relate to the current predominant cohort of later‑presenting birth-registered female teenagers. This is because the rapid increase in this subgroup only began from around 2014-15. Since young people may not reach a settled gender expression until their mid-20s, it is too early to assess the longer-term outcomes of this group (para. 3.23).
Since the rapid increase in this group began around 2015, they will not reach late 20s for another 5+ years, which would be the best time to assess longer-term wellbeing (para. 5.10).
This is an area of research where no scientific consensus exists. Schools must be aware that any claims made about the reasons behind the increase in gender-questioning children are speculative and cannot be treated as established evidence-based facts.
Early childhood gender dysphoria is not a new phenomenon. However, the existing literature on treatment and outcomes is largely based on early childhood gender dysphoria in male children. It may not apply to the current cohort of gender-questioning children who are older, predominantly female and often presenting with a range of neurodevelopmental and mental health co-morbidities.
In the last few years, there has been a significant change in the numbers and case-mix of children and young people being referred to GIDS (para 3.10).
This increase in referrals has been accompanied by a change in the case-mix from predominantly birth‑registered males presenting with gender incongruence from an early age, to predominantly birth‑registered females presenting with later onset of reported gender incongruence in early teen years (para. 3.11).
The mix of young people presenting to the service is more complex than seen previously, with many being neurodiverse and/or having a wide range of psychosocial and mental health needs. The largest group currently comprises birth-registered females first presenting in adolescence with gender‑related distress (para. 1.10).
Much of the existing literature about natural history and treatment outcomes for gender dysphoria in childhood is based on a case-mix of predominantly birth-registered males presenting in early childhood. There is much less data on the more recent case-mix of predominantly birth-registered females presenting in early teens, particularly in relation to treatment and outcomes (para. 1.28).
Secondly, the cohort that the original Dutch Approach was based on is different from the current more complex NHS cohort, and also from the current case-mix internationally, and therefore it is difficult to extrapolate from older literature to this current group (para. 5.10).
The Cass Review interim report highlights the difficulties faced by clinicians responsible for making diagnoses and recommending treatment. Teachers are neither qualified nor capable of critically evaluating existing evidence. They must carry out their duties within statutory and non-statutory frameworks. This included ensuring that any necessary referrals are made as specified by their schools’ safeguarding protocols.
Another significant issue raised with us is one of diagnostic overshadowing – many of the children and young people presenting have complex needs, but once they are identified as having gender-related distress, other important healthcare issues that would normally be managed by local services can sometimes be subsumed by the label of gender dysphoria (para. 4.10).
School staff must be clear that they are not qualified to offer students advice in this area. Moreover, the promotion of specific beliefs about the source(s) of gender-related distress could influence children’s attitudes toward the diagnostic process before meeting with a clinically trained professional. Guidance from the Department for Education states that teachers “are in a position of authority and will typically be respected and trusted by the pupils they teach, giving their personal opinions greater weight and credibility. As a general principle, they should avoid expressing their own personal political views to pupils unless they are confident this will not amount to promoting that view to pupils .”
Affirmative vs developmental models
Broadly speaking, there are two approaches to treating children with gender-related distress: the gender-affirmative approach and the developmentally-informed approach. The gender-affirmative approach is based on the theory that a child’s gender identity is innate. The developmentally-informed approach is based on the theory that a complex interaction of multiple factors underlie gender-related distress. The Cass Review interim report acknowledges that some clinicians report being under pressure to adopt a gender-affirmative approach.
Following directly from this is a spectrum of opinion about the correct clinical approach, ranging broadly between those who take a more gender-affirmative approach to those who take a more cautious, developmentally-informed approach (para. 4.15).
Some secondary care providers told us that their training and professional standards dictate that when working with a child or young person they should be taking a mental health approach to formulating a differential diagnosis of the child or young person’s problems. However, they are afraid of the consequences of doing so in relation to gender distress because of the pressure to take a purely affirmative approach (para 4.20).
There is a spectrum of academic, clinical and societal opinion on this. At one end are those who believe that gender identity can fluctuate over time and be highly mutable and that, because gender incongruence or gender-related distress may be a response to many psychosocial factors, identity may sometimes change or the distress may resolve in later adolescence or early adulthood, even in those whose early incongruence or distress was quite marked. At the other end are those who believe that gender incongruence or dysphoria in childhood or adolescence is generally a clear indicator of that child or young person being transgender and question the methodology of some of the desistance studies (para. 5.8).
School staff are unqualified to evaluate the merits of these approaches. Moreover, they have an obligation to remain politically impartial. This means not supporting one approach over another.
Social transitions (the act of treating children as if belonging to the opposite sex) are performed by some schools in England. A social transition is a powerful psychological treatment that affects a child’s psychological development. Not only are school staff unqualified to judge the appropriateness of such interventions, the outcomes are poorly understood.
Social transition – this may not be thought of as an intervention or treatment, because it is not something that happens within health services. However, it is important to view it as an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning. There are different views on the benefits versus the harms of early social transition. Whatever position one takes, it is important to acknowledge that it is not a neutral act, and better information is needed about outcomes (para. 5.19).
The Cass Review interim report acknowledges the pressures clinicians are under to adopt an unquestioning affirmative approach. Similarly, there is an acknowledgement that children are under pressure to identify with societal stereotyping. Schools cannot erase the pressures that children are under from, for example, social media and peers. However, teachers should promote acceptance for children’s non-stereotypical behaviour (boys and girls exhibiting stereotypically ‘feminine’ and ‘masculine’ behaviour, respectively) and avoid reinforcing harmful stereotypes.
Primary and secondary care staff have told us that they feel under pressure to adopt an unquestioning affirmative approach and that this is at odds with the standard process of clinical assessment and diagnosis that they have been trained to undertake in all other clinical encounters (para. 1.14).
From the point of entry to GIDS there appears to be predominantly an affirmative, non-exploratory approach, often driven by child and parent expectations and the extent of social transition that has developed due to the delay in service provision (para. 1.18).
It is not the role of this Review to take any position on the cultural and societal debates relating to transgender adults. However, in achieving its objectives there is a need to consider the information and support that children and young people access from whatever source, as well as any pressures that they are subject to, before they access clinical services (para. 2.5).
We have heard that distress may be exacerbated by pressure to identify with societal stereotyping and concerns over the influence of social media, which can be seen to perpetuate unrealistic images of gender and set unhealthy expectations, especially given how long children and young people are waiting to access services (para 4.13).
These will be considered further during the lifetime of the Review and include: . . . The complex interaction between sexuality and gender identity, and societal responses to both; for example, we have heard from young lesbians who felt pressured to identify as transgender male, and conversely transgender males who felt pressured to come out as gay rather than transgender. We have also heard from adults who identified as transgender through childhood, and then reverted to their birth-registered gender in teen years (para. 4.14).
Children with gender-related distress may pose specific safeguarding concerns. They have a higher incidence of comorbid psychiatric and/or developmental difficulties. They are also more likely to be looked after children. Teachers need to be aware of possible harms such as breast binding or tucking (of male genitals). Children may also be subjected to grooming and/or coaching, and encouraged to deceive parents, clinicians and teachers in order to secure particular outcomes such as clinical diagnoses of gender dysphoria. They may also be receiving cross-sex hormones from unregulated sources.
In addition, approximately one third of children and young people referred to GIDS have autism or other types of neurodiversity. There is also an over-representation percentage wise (compared to the national percentage) of looked after children (para. 3.11).
We have also heard about the distress experienced by birth-registered females as they reach puberty, including the use of painful, and potentially harmful, binding processes to conceal their breasts (para. 4.3).
Most children and young people seeking help do not see themselves as having a medical condition; yet to achieve their desired intervention they need to engage with clinical services and receive a medical diagnosis of gender dysphoria (para. 4.4).
We have heard that some young people learn through peers and social media what they should and should not say to therapy staff in order to access hormone treatment; for example, that they are advised not to admit to previous abuse or trauma, or uncertainty about their sexual orientation (para. 4.5).
We have heard about families trying to balance the risks of obtaining unregulated and potentially dangerous hormone supplies over the internet or from private providers versus the ongoing trauma of prolonged waits for assessment (para. 4.7).
There has been a huge increase in the number of children (predominantly female teenagers) seeking help for distress in relation to their biological sex. Research into this new phenomenon is limited. The lack of high-quality data from longitudinal studies together with the changing epidemiology means that no consensus exists about the possible causes for this recent surge in children wanting to change sex. Clinically trained professionals face difficulties in making diagnoses and recommending treatment. School staff are neither qualified to evaluate existing research nor clinically trained. Therefore, they cannot judge the appropriateness of, for example, socially transitioning children. It is an intervention with poorly understood outcomes that affects children’s psychological development. The Cass Review interim report outlines some of the specific safeguarding issues that surround gender-questioning children. School staff have a legal duty to report all safeguarding concerns according to their schools’ protocols.