Medical institutions must treat the Cass review as a significant event and act upon it

Publication of the Cass review in April 2024 was a seminal moment in contemporary medicine. Hilary Cass, a consultant paediatrician, was commissioned by NHS England to report independently on “the services provided by the NHS to children and young people who are questioning their gender identity or experiencing gender incongruence.”1 The background was an increase in referrals—of mainly “birth registered females in early teenage years”—to gender identity clinics from 2014 at an “exponential rate.”2

The conclusions of the Cass review should not be surprising to anyone who has watched the promotion of medical interventions as necessary or curative in young people with gender dysphoria. As Cass states, there is a “lack of evidence” on the long term impact of hormonal prescriptions in young people, for example. Work now begins on how to design better, more evidence based, holistic services. The conclusion that services “must operate to the same standards as other services seeing children and young people with complex presentations and/or additional risk factors” is astonishing, in that it needed to be said. We need, says the report “a different approach to healthcare, more closely aligned with usual NHS clinical practice.”2 In other words, this suggests that the approach the NHS has taken with respect to gender dysphoria has been at odds with the usual, evidence based approach taken elsewhere. This should be deeply discomfiting. As the dust settles, and we reflect on the report’s conclusions, we should ask why this has happened.

There are multiple potential explanations. One is alluded to clearly by Cass: “the toxicity of the debate is exceptional,” she writes. Indeed. I know many senior medics who were concerned about the lack of evidence for interventions, but felt their reputation and job would be under threat if they spoke up. Anonymous personal attacks online is one thing; personal abuse from senior medics for raising clinical concerns is quite another. When considered in the context of whistleblowing more broadly, medicine clearly has an ongoing problem.

But when it comes to large, well funded, professional medical organisations, there is even less excuse. The job of medical institutions is in large part to remember the mistakes of history. These organisations should respond with care, consider evidence, uncertainty, and the recurrent tendency of well meaning medicine to do harm with good intentions. Popularity should be resisted over the need for evidence and caution. This requires strong leadership. Shutting down, or trying to shut down debate about serious clinical uncertainties—as has happened—is unacceptable.

This has not been helped by the multiple lobby groups, welcomed by many institutions to influence their policy making in this area. The same rules that we would normally use to guard relationships with any other pressure group—be it promoters of disease “awareness campaigns” or party politicians looking for support—seem to have dissolved against social pressure to achieve a compliance badge on a website.

The other explanation for what has happened that I think pertinent is this. Doctors, quite rightly, have been afraid to make the same mistakes as medicine did when homosexuality was treated as an illness in the 1950s. Then, electric shocks, desensitisation, hormones, and psychotherapy were attempted to be used to “treat” homosexuality—shamefully.4 What medicine did then was to intervene—ineffectively and harmfully—in something that was not a disease and should not have come under a medical purview. As Cass states, for most young people experiencing gender dysphoria, it is temporary; it is often associated with neurodiversity; it mainly resolves over time, and medical intervention does not benefit the majority. There is a comparison, but it is in favour of medicine backing off from prescriptions and surgery, and understanding why a phenomenon might be happening, why it is being seen in a medical context, and what is the best and least harmful way to respond to such expressed and profound distress.

I urge major medical institutions to treat the Cass review as a significant event, and consider what they have contributed, both negative and positive, to the damning conclusions. Was speaking up in their organisation possible, and welcomed? Did people raising concerns have fair hearings, or were they attacked or dismissed? Did the organisation enable rational debate, or instead attempt to shut it down? Did the organisation acknowledge uncertainty and the potential for harm in current practice? I don’t expect any of that to be easy. But without understanding what has happened, we will only be ready to make the same mistakes again, just in a different set of circumstances.