The Politics Of War • Cass review delivered

• There is no simple explanation for the increase in the numbers of predominantly young people and young adults who have a trans or gender diverse identity, but there is broad agreement that it is a result of a complex interplay between biological, psychological and social factors. This balance of factors will be different in each individual.

• There are conflicting views about the clinical approach, with expectations of care at times being far from usual clinical practice. This has made some clinicians fearful of working with gender-questioning young people, despite their presentation being similar to many children and young people presenting to other NHS services.

• An appraisal of international guidelines for care and treatment of children and young people with gender incongruence found that that no single guideline could be applied in its entirety to the NHS in England.

• While a considerable amount of research has been published in this field, systematic evidence reviews demonstrated the poor quality of the published studies, meaning there is not a reliable evidence base upon which to make clinical decisions, or for children and their families to make informed choices. 

• The strengths and weaknesses of the evidence base on the care of children and young people are often misrepresented and overstated, both in scientific publications and social debate.

• The controversy surrounding the use of medical treatments has taken focus away from what the individualised care and treatment is intended to achieve for individuals seeking support from NHS gender services.

• The rationale for early puberty suppression remains unclear, with weak evidence regarding the impact on gender dysphoria, mental or psychosocial health. The effect on cognitive and psychosexual development remains unknown.

• The use of masculinising / feminising hormones in those under the age of 18 also presents many unknowns, despite their longstanding use in the adult transgender population. The lack of long-term follow-up data on those commencing treatment at an earlier age means we have inadequate information about the range of outcomes for this group.

• Clinicians are unable to determine with any certainty which children and young people will go on to have an enduring trans identity.

• For most young people, a medical pathway will not be the best way to manage their gender-related distress. For those young people for whom a medical pathway is clinically indicated, it is not enough to provide this without also addressing wider mental health and/or psychosocially challenging problems.

• Innovation is important if medicine is to move forward, but there must be a proportionate level of monitoring, oversight and regulation that does not stifle progress, while preventing creep of unproven approaches into clinical practice. Innovation must draw from and contribute to the evidence base.

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