Here's a transcript of the interview.
NMG = Nuala McGovern
HC = Hilary Cass
NMG: My first guest, however, is Dr Hilary Cass, now Baroness Cass, who led a four year review into children's gender identity services in England. Her final report, which came out in April this year, concluded that children had been let down by a lack of research and, as she put it, remarkably weak evidence on medical interventions in gender care. She called for gender services for young people to match the standards of other NHS care. Both the previous Conservative government and the current Labour one accepted all the Review's recommendations.
NMG: However, there has also been criticism and backlash from many quarters. Last month, the British Medical Association, the BMA, announced that it will carry out its own evidence-led evaluation of the Review which, it says, it will approach neutrally. So, what are Dr Hillary Cass's reflections, six months on after releasing her landmark report? She joins me now for an exclusive interview in the Women's Hour studio. Welcome.
HC: Good to be here.
NMG: So, a new government in place. You had 32 recommendations in your report. Are you satisfied with the progress thus far?
HC: I'm really pleased with the progress so far. Obviously, we have a long way to go, but NHS England has been really proactive in implementing the report. We've got two new centres up and running already. We've got another one coming online within the next couple of months and then there'll be a further one next year, and more to follow. They have picked up on the real imperative around research, so they're working with NIHR to make sure that we improve on the research base. And I think the thing that I've been really pleased about is talking to many, many clinical staff since the report was released. They feel more confident that they do have the transferable skills to look after these children and young people.
NMG: It's interesting you say that because many were wondering whether recruitment and training would be adequate for these clinics. In your final report you said you had, and I quote, hoped to take learning from these interim services, but instead you learned about the considerable challenges faced in their establishment from a highly emotive and politicised arena. And I will just give the context to our listeners that the Tavistock GIDS clinic closed in March 2024 and the others are opening - as you mentioned - other gender clinics: London, Liverpool, another in Bristol, for example. What about that, how is the recruitment and training going, particularly within that emotive and politicised arena?
HC: We've got some fantastic clinicians already working in the new services with really broad-based skills, so they've got skills in autism and in young people's health. So with, that's the first step, is treating these young people just like any other young people in distress and making sure they've got those wrap-around services. And, recruitment is slow but steady. When we did a consultation with clinicians early on in the course of the Review, what came across is they were fearful, they didn't know what to do. It was highly emotive. They knew the evidence was weak and they needed support and guidance, and I think now they recognise that these are the same young people they're seeing every day in clinic, with the same aspirations, the same fears, the same thrills and spills of growing up. And that yes, they have got the capability to see them.
NMG: What do you think they were fearful of?
HC: Well, it is a polarising area, as we know. Many of them had been told that their only role was to affirm the young person in their identified gender and refer them on to the Tavistock. And so, just ordinary things like treating depression, treating anxiety, making a diagnosis of neurodiversity - all the things they would do for any other distressed child - they weren't doing for these young people. Which was exceptionalising them, treating them differently. So these young people were just getting a worse deal than other young people.
NMG: And you are underlining there in your answer, but also have done in other places, that you wanted clinicians - and want clinicians - to look at the whole child, not only their gender identity or expression. But this holistic approach will only work if services are available in adolescent mental health, for example, to be able to refer them to these new clinics that you have outlined. Looking at some of the figures, in March 2024 - this is according to the Children's Commissioner - more than a quarter of a million children and young people were waiting for mental health support in England. And, number one, I'm wondering how can they work in the way you want them to if, in fact, there is this waiting list. And I do have a second part about that waiting - are you concerned about what the impact might be on those young people?
HC: So, we are underinvested in adolescent services, in all mental health services for young people, and there are multiple initiatives to try and address that gap. But this particular group was sitting on a sideline waiting list that didn't have the mix of staff that they needed. So, yes, all young people are waiting too long, that is true, but these young people should not be more disadvantaged than the rest. But if we can get services right across the piece, then we can get them right for this group. The bigger problem obviously needs a lot of careful thought about how we make this a more attractive area for young doctors and psychologists and other staff to come in to.
NMG: Do you think it's not?
HC: I think that it certainly can be but, one, you have shortfalls in staffing, then you can get into a vicious cycle where that's very hard for the staff in post because they're having to work so hard, so - but I think it can be fantastically interesting, not just - I'm not talking now just about gender services, I'm talking about services for young people with physical and mental health problems. It can be an incredibly rewarding area to work in and so I hope I might be able to do a pitch to attract young professionals into it.
NMG: One big change for these clinics that you have mentioned that are in the process of opening, or being open in the future, is that they won't be prescribing puberty blocking drugs, and a ban on new prescriptions of puberty blockers is now effectively in place across the UK. The only way these drugs can be accessed now, in any of the four nations, is via a clinical trial, which is hoping to start recruiting participants in the new year. But children that are already on them, Doctor, can stay on them?
HC: That's correct, yes.
NMG: So what do you say to children and parents who say with those moves, you have withdrawn gender affirming healthcare?
HC: So puberty blockers are only one part of care -
NMG: But they have been a part that has been a large part of the discussion.
HC: They have been a disproportionate amount of the discussion because, actually, the evidence doesn't show benefit for the majority of young people who go on them. And so in some senses, they have been oversold to young people as being the thing that is going to make them feel dramatically better. The commonest stage for young people to go on puberty blockers at the Tavistock was 15, by which time they were most of the way through puberty, and so it might have been better to start thinking about whether masculinising and feminising hormones were the right thing for them. But as many young people felt worse on puberty blockers as felt better, so -
NMG: But what are we looking at there when you say these figures of people feeling worse or feeling better? What studies are we looking at? What numbers are we looking at? What's the evidence?
HC: The studies are very limited, actually. There was an initial study in the Netherlands, which showed a small increase in mental health well-being, but the UK study, which had less than a hundred young people in, didn't reproduce those results. There may certainly be a small number of young people who might benefit from puberty blockers, we just don't know who they are. And we don't know whether the harms outweigh the benefits in other young people. If I was pitching any other drug to you, to give to children with that kind of data, you'd say no way, I'm not giving that to my child based on that evidence, I want better evidence. And that's what we're trying to achieve with the study.
NMG: So these are for children that are under 18 at the moment, that is the ban that is in place. And a direct statement to those that are angry that these drugs have been withdrawn?
HC: Well, they've not been withdrawn. If -
NMG: In certain circumstances.
HC: If clinical staff feel that a young person may benefit from them, they will go into the study.
NMG: A clinical trial.
HC: The clinical trial. And what I would say is we have evidence from other areas of medicine that people who are in clinical trials actually do better than people who aren't. We know that from cancer, because you look after them, you know, very assiduously and very carefully. The follow-ups are very careful. So actually young people won't be disadvantaged by going into a trial, they'll just get, we'll just get better information for those coming behind.
NMG: But for any of those right now who want to go into that clinical trial, will there be enough spots?
HC: Yes. I mean, there will be - there's no limit. In fact, you know, on the contrary, the more young people who go into the trial, the better information you can get.
NMG: A couple of other questions. Can children access puberty blocking drugs privately or abroad now?
HC: They can access them abroad. Obviously the government is in consultation about making the ban permanent so I don't want to comment further on that, on the implications of that in this country at the moment, because it's a live consultation.
NMG: You mentioned about a holistic approach to the child, asking clinicians to really be taking that into consideration when treating them, but do the alternatives to puberty blockers - let's say, cognitive behavioural therapy, or medications for depression or anxiety - is there an evidence base for that, that it works?
HC: Well -
NMG: In this context.
HC: So what we know is that there are evidence-based treatments for depression and anxiety that actually do work, and these young people haven't been getting them because they've been sitting on a waiting list, often getting no help at all. We don't know about the evidence on psychological therapies specifically to help with gender-related distress, and so for that reason I've said it's just as important that we research the non-medical interventions as the medical interventions.
NMG: You feel that they cannot do harm?
HC: That we've got no evidence that there's any harm. In fact, the team at York did a systematic review of psychological therapies and nobody deteriorated on them. There were some small improvements, but they weren't good enough samples to extrapolate from about what you should do in the future.
NMG: Your review met with resistance from some clinicians that were working in the field of gender identity. There was, for example, a study into outcomes for young people that wasn't possible because of a lack of cooperation from those clinicians. Do you feel that resistance is still as strong as ever?
HC: Well, I understand that you're talking about the adult clinics. We needed the cooperation of the adult clinics to look at follow-up data on these young people growing into adulthood, and subsequently I understand that they have now expressed a willingness to cooperate with that research, so I'm very much hoping that that can now go ahead.
NMG: Let me move to the British Medical Association, the BMA. I want to get your reaction to their decision to conduct their own evaluation of your review.
HC: Well, I found the BMA position puzzling because they haven't actually said what it is they object to about my recommendations. I mean, do they object to more services? Do they object to better training? Do they object to better research? Do they object to run-through services so children don't get lost between children and adult service? They haven't specifically said what the what the problem is.
NMG: Well, this is what I have read from the BMA Chair of the Council, Professor Phil Banfield. This is from September, says with the review "the BMA is not aiming to replicate the Cass Review. The Chair of our Task and Finish Group has set out to Council how we will listen to those with lived experience either as patients or as clinicians, consider the link between evidence and recommendation, and compare the recommendations with the actions or strategies that have arisen from them."
HC: So when they talk about listening to those that lived experience, we spoke every four to six weeks, with all of - with the main support and advocacy groups. We ran through them eighteen focus groups with children and young people. We had - those results are available on our website, of what children and young people thought. They wanted more holistic services, they wanted better trained professionals, they wanted people who respected them. We had qualitative research, which looked at experiences not just of children and young people, but we spoke to young adults through the qualitative research. So we've certainly done what the BMA say that they're going to do, but they've not got four years to do it.
NMG: So how does it make you feel when you hear that they're planning a review of your Review?
HC: Well, obviously, they need to proceed with that, but I hope that they take a balanced and careful approach and don't just cherry pick, you know, a small part of the experience and the evidence -
NMG: Is - sorry, I interrupted you -
HC: Because otherwise it won't be a meaningful review.
NMG: That's your fear?
HC: Well, we'll wait and see.
NMG: The BMA had previously called for a pause in implementing your recommendations - as you may know, but our listeners may not - and said it wanted a ban on puberty blockers for under 18s, which we have been discussing, to be lifted. Then a thousand doctors wrote an open letter opposing this. From your perspective, does this matter? This conversation within the BMA.
HC: It has an impact in terms of the fact that we're talking about it, but does it matter in terms of what's happening? No, because the Government and NHS England are fully supportive of the Review. It's being implemented. You know, today, children are walking into those new centres and being seen so, in that sense, I don't think it matters. The BMA's source of information were some online sources, mainly from the US, and those were not peer-reviewed. So I think that if, when thinking about evidence-based care, they haven't produced any evidence that the Review should be stopped.
NMG: Are you concerned, however, because I talked to - we talked a little bit previously about the resistance to some of what you were doing. If for example, clinicians, doctors are against what the recommendations are, couldn't that have a real-life impact?
HC: Well, there'll always be a spectrum of opinion in medicine, that's the way of the world. But I think the difference between the BMA's position and mine is that I've spoken to hundreds of doctors as well as other clinical staff, both during the course of the Review and since the Review, and the vast majority of those people - in national meetings, and in one-to-ones, and in work groups - are really supportive of the approach. So I feel that those who take issue with it are in a relatively smaller minority within the medical profession.
NMG: You're a retired Honorary Consultant Paediatrician. Are you still a member of the BMA?
HC: I'm no longer a member of the BMA because as a retired doctor it's not really relevant for me.
NMG: Picking up on some of the issues that we have spoken about, you might have seen the journalist Lydia Polgreen writing in The New York Times in August. She talked about your Review and she said, "it seems to have a clear, paramount goal: making living life in the sex you are assigned at birth as attractive and likely as possible. Whether Cass wants to acknowledge it or not, that is a value judgment: it is better to learn to live with your assigned sex than try to change it." That's her characterisation of your Review - do you think that's a fair comment?
HC: No. Look, if you have an enduring, long-standing trans identity, then the costs to you of medical treatments, in terms of any side effects or any negatives of the medical or surgical interventions, are trivial compared to how difficult it would be to not be able to live in your identifed gender. So for those people, it is absolutely crucial that they get the intervention, the clinical interventions that they need and that they want. The problem in children and young people is that they're in a dynamic state of development, and we just don't know which way they're going to go in adulthood. And if they go down the wrong pathway for them, then the costs in terms of medical intervention are gravely heavy to bear when some of those affects are irreversible. So it's about getting the right outcome for every single person.
NMG: But every single person, I mean - do you worry about those children that aren't able to access, or fear leaving this conversation, and this Review is stunting where they want to go?
HC: So the aim of the Review - and we were really clear about this at the outset - is not to say what being trans is or isn't, it's not about withdrawing healthcare, it's actually about trying to enhance their healthcare to make more care available. But we are on a journey on that, and I can't pretend that, you know, all the services are going to be up and running overnight. Of course they're not. But the idea is that you should be able to access care more quickly and closer to home. We have a way to go.
NMG: What's the impact been on you?
HC: For the most part, I have been really pleased to have done this piece of work. I've met some fantastic people from all sides of the debate. Some courageous people, both those who are now living successful adult lives as a trans man or woman or non-binary. I've also met some brilliant clinicians and academics, so it's it's been a really fulfilling experience. It's been disappointing that there has been the disinformation. There should be healthy debate, but the disinformation has been disappointing.
NMG: Which, I think you're referring to some that came out before your report was released, that you feel was incorrect about how the study and Review was conducted. But, you know, I did read that you were advised not to take public transport at one point due to security concerns.
HC: That was just in the very early stages, but it's not been a problem since. I got here on the train today.
NMG: You say with a smile! Do come back and talk to us a little bit further, as this conversation continues and as these clinics open, and perhaps we'll look at the progress then.
HC: I'd love to.
NMG: Dr Hilary Cass, Baroness Cass, thank you very much for joining us on Women's Hour.
HC: Thank you.