40. This is a heterogenous group, with broad
ranging presentations often including complex
needs that extend beyond gender-related
distress and this needs to be reflected in the
services offered to them by the NHS.
41. Too often this cohort are considered a
homogenous group for whom there is a single
driving cause and an optimum treatment
approach, but this is an over-simplification of the
situation. Being gender-questioning or having a
trans identity means different things to different
people. Among those being referred to children
and young people’s gender services, some may
benefit from medical intervention and some may
not. The clinical approach must reflect this.
If this applies to children the same applies to adults. With all the implications for law making and safeguarding that accompany this.
Recommendation 8:
NHS England should review the
policy on masculinising/feminising hormones. The option to provide masculinising/feminising hormones from age 16 is available, but the Review would recommend extreme caution. There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18.
Question: Why on earth did the NHS update the guidelines on hormones to adolescents just weeks before the Cass Review was due?
It makes absolutely no sense whatsoever not to wait - unless someone was DELIBERATELY politicking even at that point.
Recommendation 10:
All children should be offered fertility
counselling and preservation prior to going onto a medical pathway.
Your regular reminder of how women with physical medical conditions are regularly refused surgery related to reproductive organs on the basis that they might change their minds later. Not women who are very young but women approaching their thirties and beyond.
108. Establishment of a National Provider
Collaborative should ensure the regional
centres operate to shared standards and
operating procedures, developing protocols for
assessment and treatment. The Collaborative
should have a role in overseeing ethics, training
and professional development, data and audit,
quality improvement and research requirements,
as well as providing a forum for the discussion
of complex cases. The aim is that no matter
where in the country the child/young person
is seen, they will receive the same high
standards of evidence-based care.
No rogue clinics which you can select on the basis of their over arching ideology which was the fear of many here. Establishment of professional standards that are universal across the country with service providers held to account by a central body. This is good.
120. There is a lack of confidence among
the wider workforce to engage with gender-
questioning children and adolescents. Many
clinicians working with children and young
people have transferable skills and expertise,
but there is a need for all clinicians across the
NHS to receive better training on how to work
sensitively and effectively with trans, non-binary
and gender-questioning young people.
You mean all that training outsourced to Stonewall and Mermaids isn't good enough?! What was wrong with it? (Innocent face).
Recommendation 15:
NHS England should commission
^a lead organisation to establish a consortium of relevant professional bodies to:
^
• develop a competency framework
• identify gaps in professional
^training programmes
^
• develop a suite of training
materials to supplement professional competencies, appropriate to their clinical field and level. This should include a module on the holistic assessment framework and approach to formulation and care planning.
Removal of power from Trusts on this by the looks of it and a centralised quality controlled internal training framework. Stonewall are not compatible with these criteria.
142. Discussions with clinicians highlighted the
importance of differentiating the subgroups
within the referred population who may be at risk
and/or need more urgent support, assessment
or intervention; there may also be subgroups
for whom early advice to parents or school staff
may be a more appropriate first step.
Teaching unions have an issue with regards to their current political position and their legal duty of care responsibilities... Massive conflict of interest here.
156. GPs have expressed concern about
being pressurised to prescribe hormones after
these have been initiated by private providers
and that there is a lack of clarity around their
responsibilities in relation to monitoring.
157. The Review understands and shares
the concerns about the use of unregulated
medications and of providers that are not
regulated within the UK. Any clinician who
ascertains that a young person is being given
drugs from an unregulated source should make
the young person and their family aware of the
risks of such treatment
Well that's not difficult to work out who that's being aimed squarely at.
NHS number
161. Currently, when a person requests to
change their gender on their NHS record,
NHS guidance requires that they are issued
with a new NHS number. This has implications
for safeguarding and clinical management of
these children and young people and could
affect longer-term health management
(for example, the screening they are offered).
162. From a research perspective, the issuing
of new NHS numbers makes it more difficult to
identify the long-term outcomes for a patient
population for whom the evidence base is
currently weak.
Question: Should DBS forms be tied to NHS numbers to prevent issues arising from Name Changes? This would work if you can't change NHS numbers.
• A major problem in making sense of trial findings is bias. There are many ways in which
^results can be biased. For example, if 50% of the sample drops out, this would be referred to as a high attrition rate. It’s possible that the people who remained in the study are those who responded well to the treatment, whereas those who dropped out did so because the treatment wasn’t working for them or they had bad side effects. This could result in a positive bias in the study outcomes; in other words showing an effect when there isn’t one.
It could also fail to show the side effects that caused people to drop out.
^
• Another way of biasing results is if the patients in the treatment and control groups
^differ in some way; for example, one group has more people who are younger, or sicker.
^Researchers will assess the groups on several measures and compare them to see if they are similar at the start of the study (baseline assessment). Random allocation of people to the study groups and large numbers of participants help reduce the risk of differences between study groups.
• It is very important to get the inclusion and exclusion criteria of a study right (that is,
which patients can and cannot be included). For example, a trial might report that a
painkiller is highly effective, but if it turns out that only people with osteoarthritis in the knee were included it would mean that the results cannot be generalised to patients with headache. Although the drug may work very well for headache, it is not possible to be sure about this on the basis of findings of this particular study.
• In any design where patients are not blinded and know they are getting a particular
^drug, or where they have chosen a specific treatment rather than being randomised to one, they may show improvement because of a placebo effect (that is, they believe that the treatment will produce a beneficial outcome).
^
• Sometimes there are confounding factors in a study, such as the patient getting another
treatment at the same time as the trial treatment. Though randomisation and blinding
^minimise the risk of bias and confounding, this is notcompletely watertight.
^
• There must also be enough patients in a trial (the term ‘sufficiently powered’ is often
^used where there are) to be sure the results reflect the range of possible outcomes and do not give a ‘positive´ result by chance, a so-called Type 1 (or alpha) error. Study outcome measures are generally reported as the average for a group, but the range is usually also given and can be very wide. For example, if the average outcome for a group is 5 points out of a possible 10, a range of 2-9 would indicate much more varied outcomes across the group than a range of 4-6. Size influences whether the reported outcomes are statistically significant. In very small studies, for example one with only
four patients put on a treatment and in which three got better and one got worse, it would not be possible to understand the full range of possible outcomes. Furthermore, the benefits for three individuals could have happened by chance. For a result to be statistically significant, it must be unlikely that the result could have happened by chance. This is why substantial numbers of participants are required and a key requirement of any trial is a pre-recruitment estimate of how many will be needed for the study to produce meaningful results.
• There are many other potential problems, some of which include:
^
- unconscious bias in questionnaire design where the questions are written
^in a way that prompts a more favourable response;
^
- using the wrong kind of analysis for the available data;
- not following up for long enough to see the full benefits or harms of a treatment;
- seeing an improvement because patients were improving spontaneously over time;
- publication bias where, for example, only positive results are published.