The Cass Review into Gender Identity Services

The Independent Review of Gender Identity Services for Children and Young People, led by Dr Hilary Cass OBE, published its Interim Report on 11 March 2022.  The main focus of the report is the medical care and treatment of children at the Gender Identity Development Service (GIDS).  The full report, due in a few months, promises to consider the important role of schools and the challenges they face in responding appropriately to gender-questioning children and young people.  In advance of this the Interim Report has some findings that are very relevant to schools now.

We thank the Bayswater Group for their assistance with this analysis, and for their continued work in supporting families of trans-identified children.

Social transition is not a neutral act

“Social transition – this may not be thought of as an intervention or treatment, because it is not something that happens within health services. However, it is important to view it as an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning.  There are different views on the benefits versus the harms of early social transition. Whatever position one takes, it is important to acknowledge that it is not a neutral act, and better information is needed about outcomes.” (p62)

Schools should be aware that social transition – changing a child’s name and pronouns – is not neutral.  It is an active intervention.  The Cass Review has not yet been able to ascertain whether it is beneficial or harmful, or how this may change in different circumstances.  In the absence of evidence that it is beneficial, schools should not take what is effectively a clinical decision on treatment.  Schools do not have the necessary medical expertise to make this judgement.  They should not try to encourage or pressurise parents to agree to social transition, nor do this without parental consent.

If parents have requested that a child’s name and pronouns are changed, the legal situation will be different.  However, schools should still be aware that if the child is not under appropriate medical care, social transition is an active intervention with as yet unknown long-term effects.

Our Advice Note on Social Transitioning by Schools sets out some of the things that schools should take into account before they consider socially transitioning a child.

Many schools are under the impression that children who are ‘Gillick competent’ can decide to socially transition without parental agreement.  There is not yet any case law on this.  In reading the Cass Review schools should consider whether it is likely that a child would be able to consent to something that has unknown effects and outcomes. 

Schools should take note of the findings from the December 2020 Bell v Tavistock judgment that children aged under 13 are highly unlikely to be able to give informed consent to treatment with puberty blockers and that for children aged 14 and 15 it is very doubtful. Although it was decided on appeal that doctors are able to continue prescribing puberty blockers to children under 16, the finding that children are not able to meaningfully consent was unchanged. The court acknowledged that administration of puberty blockers almost invariably lead to administration of cross-sex hormones. 

Although social transition does not involve medication, the link between social transition and subsequent medicalisation is not known and therefore schools should proceed with extreme caution.

Schools must also consider their PSHE programme and look critically at the many resources that promote social transition and affirmation-only as ‘kind’ and any other views as ‘hurtful’ and likely to cause emotional harm and even suicide among trans-identified children.  The Cass Review has not yet been able to draw conclusions on whether social transition is beneficial – therefore schools cannot make clinical judgements on the benefits and harms.

The affirmation-only approach is at odds with normal clinical care

“Primary and secondary care staff have told us that they feel under pressure to adopt an unquestioning affirmative approach and that this is at odds with the standard process of clinical assessment and diagnosis that they have been trained to undertake in all other clinical encounters.” (p17)

“Clinicians and associated professionals we have spoken to have highlighted the lack of an agreed consensus… Following directly from this is a spectrum of opinion about the correct clinical approach, ranging broadly between those who take a more gender-affirmative approach to those who take a more cautious, developmentally-informed approach.” (p47)

School policies that require or expect affirmation of children’s ‘gender identity’ are at odds with standards of clinical care.  As stated in the Cass Review, social transition is not a neutral act.  Requiring school staff and pupils to affirm others may not be in the best interest of the child.  Schools are not in a position to make clinical judgements on psychological treatments.

Developmental stages

“It is not unusual for young people to explore both their sexuality and gender as they go through adolescence and early adulthood before developing a more settled identity. Many achieve this without experiencing significant distress or requiring support from the NHS, but this is not the case for all.” p27

“Regardless of the nature of the assessment process, some children and young people will remain fluid in their gender identity up to early to mid-20s, so there is a limit as to how much certainty one can achieve in late teens. This is a risk that needs to be understood during the shared decision making process with the young person.” p36

Schools must remember that normal child and adolescent development involves periods of change and sometimes discomfort, and that expressions of ‘gender identity’ or trans-identification should not be artificially solidified by external affirmation. As always, schools must adopt a safeguarding first approach.

Autism, neurodiversity and other factors

“In addition, approximately one third of children and young people referred to GIDS have autism or other types of neurodiversity.” (p32)

“Parents have also raised concerns about the vulnerability of neurodiverse children and young people and expressed that the communication needs of these children and young people are not adequately reflected during assessment processes or treatment planning.” (p46)

“As previously indicated, the epidemiology of gender dysphoria is changing, with an increase in the numbers of birth-registered females presenting in early teens…There is also an over-representation percentage-wise… of looked after children.” (p58)

The Cass Review highlights the disproportionately high numbers of children referred to GIDs who have autism and other types of neurodiversity as well as complex mental health issues. Autistic children often struggle with social conventions and do not conform to the gender stereotypes that are associated with their sex. The interpretation of this as a sign of trans identity is an issue of concern to many in the autistic community.
Looked after children are also over-represented.  Schools should be aware of this and remember that in the absence of appropriate medical guidance for individual children, they should not take action that could ultimately cause harm.