nhs england Archives

Trans children, young people and their families have been faced with hateful narrative and misformation since the publication of The Cass Review on 10 April 2024.

Media organisations and elected representatives hostile to trans youth have sought to misrepresent the report’s findings and call into question the validity of their experiences, and we are deeply disappointed, although not surprised, that Dr Cass’ own calls for compassion and respect have been completely disregarded.

As a charity supporting trans youth and their families, our focus these past few weeks has been on reassuring those worried by the content of the report as well as the irresponsible way it is being interpreted.

Since publication, we’ve met with Dr Cass and the review team alongside other LGBT+ support organisations to share concerns we’ve been hearing from our community. You can read about the questions they answered at the Kite Trust.

Our analysis is focused on what children, young people and families need to see in response to the review, and on how this could be delivered.

You can find out more about what other organisations are saying about The Cass Review at Stonewall, Scottish Trans and TransActual. You can also read our short explainer giving more context to the Cass Review, and what it means.

Overall analysis

While we have significant concerns about many aspects of the report, it recognises the existence of trans children and young people and rightly acknowledges what they have been saying for years: NHS services are comprehensively failing them.

Young people we have spoken to are concerned about what they have read, including the desire to understand “why” young people are trans, and to place what feel like “limits” on gender expression, further pathologising and medicalising their identities. We share these concerns.

We are deeply frustrated with the lack of clarity throughout the report, which has enabled wilful misinterpretation and the spread of harmful misinformation. Clear and accessible language is vital, especially when services are operating in a context where there is significant hostility to and misconceptions about trans people, particularly in the media.

“I don’t experience minority stress from ‘lots of different opinions’ – I experience minority stress because there is open and vitriolic conversation about how we don’t understand ourselves or our bodies, that we don’t deserve to exist, that we’re somehow evil and perverted or manipulated by something evil and perverted.”

The Cass Review team appears to have heard community concerns and agreed to publish more information providing clarity on the most troubling and misrepresented aspects of their report.

Beyond this, it is critical that NHS England and the Department for Health and Social Care (DHSC) listen to trans children and young people, their families and the trusted adults in their lives in shaping services, and resist pressure from those using the Cass Review in bad faith to further restrict access to healthcare and limit trans young people’s freedoms.

Timely access to holistic, supportive care should be available close to home for all trans children and young people, including access to medical interventions such as puberty suppressing and cross gender hormones, and we will continue to campaign robustly for this.

We call on NHS England to provide urgent upfront investment in these services, as well as the infrastructure and workforce to address the significant backlog caused by years of underinvestment and politicisation of the lives of trans children and young people.

Key concerns

Social Transition

The Cass Review does not, as has been misrepresented in the press, recommend a blanket ban on social transition for any age group, and specifically recognises the rights and agency of young people to present how they choose. Dr Cass calls for early access to support for young children and their families so that they can be supported around decisions relating to social transition.

However, Dr Cass recognises that “there is no single definition of social transition” but then goes on to speak of “full” and “partial” social transition, without clarity.

As well as this lack of clarity, young people have told us that they are frustrated by the report’s desire to pinpoint a “cause” for trans young people to be open about who they are and are worried that it may be interpreted to limit social transition, particularly in schools.

“Why is there a failure to see that maybe just maybe if children socially transition and go onto medially transitioning it’s because they are trans!!!! And not because socially transitioning altered their development”

We have already seen this misrepresentation spoken in parliament, and we completely reject the words of Government ministers suggesting that being trans is anything other than a healthy and important way for young people to express themselves.

It is vital that both NHS England and the Department for Education consider the full recommendations of the Cass Report in the development of services and updated guidance relating to trans young people.

We will continue to advocate for supportive schools, where young people are able to express themselves authentically.

Puberty Suppressing and Gender Affirming Hormones

The report acknowledges the efficacy of puberty delaying treatment for some trans young people, while arguing that the evidence base is insufficient. The report also recognises that most young people receiving puberty suppressing treatment on the NHS aren’t doing so until it is too late for them to be effective (an average age of 15) as a result of long waiting lists and significant barriers to accessing care.

The report also calls for “extreme caution” in prescribing gender affirming hormones to 16 and 17 year olds, which has already led to a review of prescription policy for all over 16s announced by NHS England, and the convening of a new multi-disciplinary team to oversee prescriptions for 16-17 year olds. We believe this is a knee jerk reaction from NHSE which may delay access to care.

There are questions about the way in which existing research has been used, evaluated and in some cases excluded from the review’s consideration. Dr Cass has agreed to provide clarity on this.

We have significant concerns about mandatory participation in research as a condition of access to treatment, and the way in which this area of gender care has been politicised far more than any other.

We call on NHS England to reassure 16 and 17 year olds that their care will not be delayed, to speed up work on research trials, and to ensure that this is done so transparently, ethically and in line with international best practice.

Services for Young Adults

Young people have told us that they are worried by suggestions in the media that Cass has recommended a block on transition until 25, particularly for neurodivergent young people.

The report recognises that there are huge gaps in support for young people due to long adult waiting lists and the end of youth services at 18.

We agree that no young person should be left without gender care at 18, and that there should be a seamless transition into adult services when it’s right for them. It’s also important that young adults who have been seen by children’s services are able to access the same care as their peers who first sought care as adults.

Instead of setting out what these services might look like, and committing to ensuring seamless support for young adults, NHS England immediately required adult services to cancel appointments for 17 year olds, many of whom have been waiting many years to access support. We call on NHS England to reverse this harmful decision and ensure support is offered to all 17 year olds who have been removed from children and young people’s waiting lists.

NHS England must rapidly reassure young people and families that access to adult services remains unaffected while they develop and appropriately fund seamless follow-through service.

Private Care

Free access to healthcare is a fundamental right. Due to the failure of the NHS to provide this to trans children and young people, many have been forced to access care outside of the NHS, at significant financial cost.

The review makes unclear recommendations about private and overseas care which may have implications for those using these services, both in their ability to access this care, and potentially accessing NHS services in the future.

We have heard from families where young people have been on NHS waiting lists for five or more years and have accessed private services both overseas and in the UK. They feel that the NHS has abandoned them, and that the Cass Report has provided NHS England and the DHSC with a blueprint to further restrict access to care for young people who have been failed by existing services.

Restricting access to these routes will likely result in people taking even more risky approaches, and reduce the likelihood that they will disclose this to supportive health professionals and trusted adults, increasing the physical, financial and safeguarding risks they face.

The NHS and DHSC must ensure a non-punitive, harm reduction approach for all young people in these situations. This includes not applying restrictions to accessing NHS care and support for those who have used other forms of care and ensuring that primary and secondary care providers are equipped to provide harm reduction measures, such as monitoring.

Neurodivergence

The Cass Report acknowledges that neurodivergence and mental health conditions are common among trans young people, and that these young people require a holistic approach to ensure that all their needs are supported.

However, there’s no clarity about why all young people should be screened for these conditions, what impact this will have on access to specialist gender care, or on waiting times.

We are also concerned that the report implies that neurodivergent young people who are autistic are less trustworthy in articulating their trans identity than their neurotypical counterparts or that this capacity is limited until their “early 20s”.

NHS England must clearly articulate that neurodivergence, disability or other health conditions will not impact on access to gender affirming care, including through longer waits caused by lengthy waiting lists for full assessment for other conditions. This includes ensuring clarity around the rights and agency of neurodivergent young people in line with Gillick competency.

What next?

We’re talking with colleagues across the LGBT+ and youth sectors about the actions we’re going to take to ensure timely, holistic and supportive healthcare for trans young people, and will keep you updated on our next steps.

We’ll be talking more about what the Cass Review could mean for trans youth on our Instagram next week. In the meantime, to keep up to date with our healthcare campaign, join our mailing list and if you’d like to support our work, you can make a donation.

If you need support, contact our helpline. We’re here for you Monday to Friday, 9am-9pm.

Everyone deserves access to timely, supportive and holistic healthcare. However, across all of the UK, the NHS is failing trans youth, with appalling waiting lists of more than six years, virtually no first appointments offered for over a year, and increased politicisation of the support offered to children and young people.

Trans youth tell us they want services which are accepting and respectful, which offer supportive spaces to explore their gender, and provide access to medical transition if and when they need it.

The Cass Review, an independent review of NHS England gender services for children and young people, published today (Wednesday 10 April) after almost four years, echoes much of this and recognises the current system is failing trans youth.

We are pleased the voices and experiences of trans young people appear to have been heard and respected, and we welcome Dr Cass’ calls for trans children and young people, and their families, to be “treated with compassion and respect”. We hope for the same, and for the sharing of clear, accurate information when discussing this topic.

However, we are concerned that some of the language in the report is open to misinterpretation and could be used to justify additional barriers to accessing care for some trans young people in the same way the interim report has been. We will publish our full analysis of The Cass Review in due course.

NHS England has published their immediate response to The Cass Review and written to all adult providers, explaining the changes they plan to make in the short to medium term. Very few of these will have an immediate effect on children and young people, and we will keep trans young people and their families informed about any changes that might impact them.

In the meantime, we call on NHS England, and the NHS across the UK, to resist pressures from those who seek to limit access to healthcare, listen to trans youth directly, and act urgently to provide gender services which are timely, supportive and holistic.

If you need support or have questions about what this might mean for yourself or your young person, please contact our helpline team. We’re here for you Monday – Friday, 9am – 9pm.

NHS England has today (12 March 2024) announced that from 1 April they will no longer routinely prescribe puberty blockers. They will be available in the future, but only through a mandatory research trial.

This announcement is deeply disappointing, and a further restriction of support offered to trans children and young people through the NHS, which is failing trans youth. There were virtually no first appointments offered in 2023, with ever-growing waiting lists of over five years.

Those currently prescribed puberty blockers won’t see any changes to their treatment, and this is a pause on prescribing – not a ban. It’s also important to note that puberty blockers can be just one possible part of a young person’s gender journey. However, this news still comes as a blow and will deeply affect our communities.

As well as providing support to children, young people and families, as we have for 29 years, Mermaids will continue to advocate strongly for access to timely, holistic and supportive healthcare for trans youth, including access to puberty blockers for those who need them. Everyone deserves access to healthcare, and to live happy and healthy lives. Trans youth are no exception.

If you need support, please contact our helpline on 0808 801 0400. We are here for you.

“It sounds like they are trying to stop trans youth existing”

This month, we published a blog summarising some of the proposed changes to the NHS healthcare services for young trans and gender-diverse people in England.

The new guidelines were met with anger and frustration by the young people and families we support, with those on our helplines and forums expressing deep concern about the implications to their future wellbeing.

In response, we held two online engagement sessions, one for trans and gender-diverse young people, and one for parents to listen to their views.

What struck us most was the message that, in their current form, the proposals categorically fail our communities. Participants strongly felt that NHS England appears committed to denying trans young people the right to be their authentic selves.

“Literally everyone transforms themselves socially in some way or another”: The right to socially transition

Under the new guidelines, clinicians are now advised to only consider supporting “social transition” – i.e. changing name, pronouns, clothing – if a young person experiences what is described as “clinically significant distress“.

There was shock amongst young people at this inclusion within the guidelines, who felt this is reflective of efforts to “medicalise” trans people. In other words, it opens up the possibility that a person will require permission from a doctor to dress how they please, and use their chosen name and pronouns.

As one young person remarked, social transition is “a thing that people should be allowed to do freely because people, even children, have bodily autonomy.”

Both parents and young people recognised the enormous benefits that social transition can bring to a child’s mental well-being, so far as to be life-saving for some.

There was bewilderment that someone could only access support if they reached the point of showing “significant” distress. “Why would they want young people to get to that point?” one young participant observed.

Rather than uplift and support trans youth, our participants felt the proposed changes deny them the right to express themselves as they choose – something one parent suggested could be seen as “conversion therapy”.

“I don’t think it’s about increasing the capacity to help more people”: The right to access care

Currently, young people can be waiting over three years to just have a first appointment with gender services.

Everyone we heard from felt it is a priority to urgently reduce the waiting lists but there was concern that the guidelines would create additional barriers and delays to care.

Under the proposals, a young person can only be referred to gender clinics via their GPs or NHS professionals. Both young people and parents shared negative stories from local doctors, with some having to deal with GPs with no knowledge of trans healthcare, while others had experienced outright hostility.

The requirement for an additional assessment stage before joining the waiting list will not only create further delays, but also risks retraumatising young people seeking healthcare.

One young person mentioned that the “whole process is a hoop-jumping and emotionally taxing exercise which is inevitably going to be a problem for those with additional needs” such as those who are neurodiverse.

This view was echoed by a parent who told us how her child had “already had to speak to 10 or 12 people” about their body. “Why should I force my child to traumatise themselves just to get medication?”

“Not acting is not neutral: hearing your children saying I am, you know, whatever gender they are, and doing nothing, that’s where you need to go to social services”: The right to be heard

These excessive delays and barriers are leading families, who can afford it, to seek out private healthcare for their young person.

The proposals encourage a GP to make a local safeguarding referral if a young person accesses medications through a private provider, putting families in the unenviable position of choosing between either listening to what their child wants and needs through private care, or being unable to access vital support from their GP.

Far from reducing possible harm to trans young people, the guidelines are a dereliction of the duty of care towards an already marginalised community.

Both young people and parents were very clear that the proposed changes reflect a complete lack of understanding of the experiences of trans people and those who support them. “If you are trans, or you have a loved trans person in your family, you get it. But if you don’t, you don’t. And that’s the problem” one parent told us.

We asked our young people if they could encourage the NHS to change one thing, what it be. “We know ourselves better than you ever will” was one response.

It’s time we started listening to, trusting and believing trans and gender-diverse young people and their supportive families, placing their needs front and centre in the design of new healthcare services.

These proposals are not final and we have produced guidance to help those wishing to take part in the consultation.

Regardless of the outcome, Mermaids will continue to campaign for a world where trans young people can thrive in every aspect of their lives.