NHS considers review of adult gender services following Cass criticism

The NHS has drawn up plans for a safety review of adult gender services, in response to detailed concerns raised by the author of the Cass report into gender care for children and young people.

Leading consultant paediatrician Dr Hilary Cass has listed 16 separate concerns about the quality of treatment offered to adults with gender dysphoria in a strongly worded letter to NHS England.

In response, NHS officials pledged to speed up reviews of these services and announced that inspections of clinics would begin in September.

Cass said that during her three-year investigation into women’s care for children services, she was approached by a number of staff working in adult women’s care clinics who reported inadequate consent processes, limited explanations of the risks of treatment, “chaotic” administrative processes, “out of control” waiting lists, a lack of national guidelines on hormone treatment and a lack of systematic follow-up processes.

Cass was told that patients were not always informed about the “irreversibility of some effects” of treatment. Some clinicians told her they were concerned that colleagues were failing to correct or challenge patients’ “magical thinking,” “i.e. unrealistic beliefs about what could be achieved through medical transition,” she wrote in the letter sent in May and published on the NHS England website earlier this month.

In response to these reports, NHS England has outlined details of a new review, to be led by Dr David Levy, assessing “not only the quality (i.e. effectiveness, safety and patient experience) and stability of each service, but also whether the existing service model is still fit for purpose for the patients it serves”.

Mr Levy, a cancer specialist and medical director of Lancashire and South Cumbria Integrated Care Board, will be supported by a panel of expert clinicians, patients and representatives from the Care Quality Commission.

NHS England has also published details of its plans to expand services for young people, increase workforce training, improve research and explore providing support for patients seeking gender reversal and detransition.

Cass wrote that she had heard concerns from some clinicians working in adult support services that the approach to care was “ideologically driven and polarised and it was difficult to challenge that approach or discuss those concerns”.

“The very limited time allowed for assessment and the expectation that patients would be placed on hormones by their second visit was a common concern,” she wrote. “The majority of patients were extremely complex, with a mix of trauma, abuse, mental health diagnoses, forensic histories, ASD, and ADHD. Therefore, this limited assessment was inadequate.”

Concerns have been raised “about the marked change in the composition of cases from a predominance of older males registered at birth to a predominance of females registered at birth in their early twenties with complex presentations,” she wrote.

The Cass report into children’s services, published in April, recommended “follow-up services” for young people aged 17 to 25, to avoid young people being transferred straight into a radically different model of adult services.

The Cass report was welcomed by Labour and the Conservatives, as well as NHS England, upon its publication. However, last month the British Medical Association voted in favour of a motion criticising the study and called for a pause in implementing its recommendations.

A spokesperson for the Cass Review defended its research standards.