Cass Review

Baroness Merron Excerpts

Wednesday 17th April 2024 Lords Chamber

[Baroness Merron (Lab)]

My Lords, Dr Cass and her team are to be thanked for their rigour and their care with this report, in which they have navigated many complex and sensitive issues. This review into the NHS’s gender identity services concludes that children and young people have been let down by inadequate research and evidence on medical interventions, and they have been failed by inadequate services amidst a debate which has, sadly, been marked by extreme toxicity.

At the same time, at the heart of the complexity around gender identity services are two aspects that are simultaneously true. There are trans adults who have followed a medical pathway and say that, for all the pain and difficulty involved, it was not just life-affirming; it was life-saving. There are also people who followed a medical pathway and say that it has ruined their lives irreversibly and ask how anyone could let that happen. For those children, young people, and now adults, but particularly those who are being referred into gender identity services today, there is a duty to get this right.

The Cass review refers to many scandals, which exposes both the inordinate amount of time that children and young people are waiting for care while their wellbeing deteriorates, and medical interventions that have been made on what could be called shaky evidence. Can the Minister say how it came to be that NHS providers refused to co-operate with this review? How was it allowed that adult gender services would not share data on the long-term experience of patients? What accountability does the Minister feel that there should now be?

The Minister will know that the discussion around the substance of the review has been highly toxic. People have felt silenced, and it has required investigative journalism to prompt this review to take place. Tribute should be paid to journalists, including Hannah Barnes, and to the whistleblowers, who together helped shine a light on the Tavistock clinic. It is concerning to note that Dr Cass said that the

“toxic, ideological and polarised public debate has made the work of the review significantly harder”,

and that will

“hamper the research that is essential to finding”

a way forward. This particularly vulnerable group of children and young people is at the wrong end of the statistics when it comes to mental ill health, suicide and self-harm. They have been badly let down, so we owe it to them to approach this discussion with the sensitivity it demands.

Parts of this report today will sound very familiar: services unable to cope with demand; significant staff shortages; a lack of workforce planning; and unacceptably long waits for the mental health support and assessments that children and young people need, such that in some cases children become adults before they even get a first appointment with the gender identity services. To this point, the Cass review recommends a follow-through of services up to the age of 25, to ensure continuity of care. Will the Minister indicate how long it will take to establish these services, and could the Minister set out what plans there are to cut waiting times for assessments for mental health and neuro- developmental conditions?

Last month’s decision by NHS England to stop the routine prescription of puberty blockers to under-18s is welcome. However, the loophole that exists for private providers risks illegal trading. In the other place, the Secretary of State said that she expected private clinics to follow the report’s recommendations to follow the evidence. I underline our support for these expectations on compliance. Does the Minister consider that further regulation might be needed to enforce the recommendations? Could he say something more about the timescales involved in making progress, both for the CQC to incorporate the recommendations into its safe care and treatment standards and for NHS England’s urgent review on clinical policy for cross-sex hormones?

Children’s healthcare should always be led by the evidence and be in the best interests of their welfare. Dr Cass’s report has provided the basis on which to go forward. This report must also provide a watershed moment for the way in which society and politics discuss this issue. There are children, young people and adults, including trans children, young people and adults, who are desperately worried and frightened by the toxicity of the debate. There are healthcare professionals who are scared to do their job and make their views known. I hope that we can now put children’s health and well-being above all else.

[Baroness Burt of Solihull (LD)]

My Lords, I believe that the Cass review is an extremely thorough summary of where we are now and of the pathways available to young people that we need to explore. Most importantly, this report gives a way forward for young people and their clinicians who feel anxious and frightened because they find themselves at the centre of a political maelstrom.

Interestingly, the most balanced response I have seen to the report came from Stonewall, which was consulted by Cass, and I have used some of its points here. Cass says that these youngsters have been sorely neglected by the NHS, which sidelined them away from mainstream care to services that have fallen short. She points to how we can start the process of making it up to them, by giving them the holistic care that they need and deserve.

Despite the way in which the report was received by certain gender-critical individuals, it does not question trans identities or recommend rolling back healthcare access. It does not say that puberty blockers are unsafe or dangerous. It does say that there is insufficient and inconsistent evidence about some of the effects of puberty suppression. In addition, it notes that cross-sex hormones are well established and have transformed the lives of trans people, and supports their use from the age of 16. Importantly, it does not, at any stage, suggest a ban on social transition for any age of child or young person, but recommends that this be done with the support of parents and clinicians.

Cass says that gender incongruence is a result of a complex play between many biological, psychological and social factors, of which sexual orientation can be one. There are many factors, and no simple answer. For example, saying that such young people are simply confused gay people, unhappy teenagers, or that it is all the fault of social media, is all too simplistic. Regrettably, this has not stopped the Government spinning their own version of who is to blame.

For example, this week’s Statement by Secretary of State Victoria Atkins said that Tavistock clinicians “almost always” put children on an irreversible path of blocking puberty, then prescribed cross-sex hormones and on to surgery as an adult. This is not my understanding of the situation. In 2019-20, only 161 under-19s were referred by gender identity development services for puberty blockers. It was estimated that only around one in six GIDS patients ended up being prescribed puberty blockers. Is not the picture bad enough, without painting something even worse?

There are currently more than 5,000 children on the waiting list for treatment. The NHS has confirmed that everyone currently on puberty blockers via the NHS—fewer than 100 children—will be able to continue on them. These children, and any new recommendations for puberty blockers, will not be prescribed unless they agree to take part in a clinical trial to test the effectiveness of puberty blockers properly. How long does the Minister estimate that it will take for this clinical trial to be set up? Speaking of waiting lists, I understand that it currently takes three years for a child on the list even to be seen. How will the trial ever be set up, except for the few now on puberty blockers, while the rest languish for years on waiting years while their puberty seeps away? Does the Minister not agree that it is time to make up this shocking treatment which has, or rather has not, been given to children by the NHS and put them immediately on a par in priority with other NHS services?

These are our children. They, and the clinicians who want to treat them, have been intimidated by the toxic environment that we have all helped to create. I have heard the Cass report described as a rock that we can now all cling to. We will never all agree about some quite fundamental issues regarding trans and the nature of trans, but we must never make our children suffer for it; we must never make them pawns in a zero-sum game. We must rise above it and argue well, with more light than heat, to protect our children, who, after all, must be at the centre of all we seek to do.