What is the Cass Review?

In 2020, NHS England launched an independent review of children and young people’s gender services in England, led by Dr Hilary Cass. The review had a massive scope, including:

• What care trans youth received
• How they get to and through the service
• What medical options are available
• How to staff services
• How to explain the changes in demand for the service.

They also commissioned a set of research from the University of York.

Mermaids has regularly engaged with Dr Cass, most importantly through platforming trans children and young people’s views directly to the team through a series of focus groups. We have, however, been disappointed with the review’s consistent engagement with groups who deny the existence and legitimacy of trans youth.

What did the Interim Report say?

In 2022, Dr Cass produced her Interim Report. She wrote to trans youth saying “I think that more services are needed for you, closer to where you live”, and that success would be measured by “timely, appropriate and excellent care… from every healthcare professional they encounter”. 

Mermaids supported the proposal to expand services across England’s regions, to better train healthcare professionals, and to build a consistent, holistic approach to healthcare (from GPs to specialised services). 

However, we were concerned by parts of Dr Cass’ report, which fell into common misconceptions that gender-affirming care doesn’t allow space for open, supportive exploration. 

The report also inferred that being trans could be caused by adverse childhood experiences, neurodiversity or sexual orientation, which we wholly reject.

Finally, her report was clear that preventing social transition is “not a neutral act”, but her words have been widely used by anti-trans activists to argue against trans youth’s self-expression. 

While skeptical of the review’s approach, including the lack of trans people or experts in trans healthcare in the team, Mermaids conducted research with trans youth to ensure the Cass Review heard directly from them.

What do trans youth want?

Mermaids works directly with trans children and young people to listen to and platform their voices, with lack of adequate healthcare and support consistently their top concern. We held a series of focus groups specifically on the Cass Review, where trans youth told us they want:

• Reasonable waiting times for a first appointment (currently at 6+ years)
• Services which help people with their gender dysphoria, to grow confidence, and become more comfortable in themselves
• Interact with accepting, supportive and respectful healthcare staff specifically trained in trans-inclusion, ideally including trans people themselves
• Ensure neurodiversity doesn’t prevent support for transition 
• Any assessments should start from a point of respect, and feel less like being on trial
• The process should involve asking the patient what they want out of the process, with a wider offer including voice training, laser treatment, and signposting to LGBTQIA+ youth groups
• Services should feel welcoming, less clinical, and accessible for disabled people
• Referrals into the service should be from a wide variety of sources, based on those the young person is most comfortable disclosing to – including schools, youth groups and family

What happens next?

NHS England did not wait for the Cass Review to conclude before making radical changes to the gender services offered in England for children and young people. The previous provider, GIDS, was closed last week, with two new services (much delayed) opening in the North and South, which will expand to 7-8 regional services. 

These services operate under a new set approach (specification), which we fear over-medicalise and restrict care. They have also removed puberty blockers from routine prescribing, which will only be available through a research protocol in the future.

Following the final Cass Review, which is expected in the next few weeks, NHS England will review her recommendations and likely produce an updated set of policies and specifications in the coming year to reflect them. 

We’ll be analysing the review closely when published, and will continue to advocate for the young people we support, pressing for timely, holistic and supportive healthcare for trans youth across the UK.