NHS plans review of adult gender services following Cass criticisms

The NHS has set out plans for a review into the safety of adult gender services, in response to detailed concerns raised by the author of the Cass report on gender care for children and young people.

Dr Hilary Cass, the leading consultant paediatrician, listed 16 separate points of concern about the quality of treatment being offered to adults with gender dysphoria in a strongly worded letter to NHS England.

In response, NHS officials have committed to expediting a review of these services, and announced that clinic inspections would begin in September.

Cass said that during the course of her three-year investigation into children’s gender services, she was approached by a number of staff members working in adult gender clinics. They reported inadequate consent processes, limited explanation of the risks involved in treatment, “chaotic” administrative processes, “out of control” waiting lists, an absence of national treatment guidelines regarding use of hormones and a lack of systematic processes for follow-up.

Related: ‘I’ve had to become my own doctor’: trans young people on life after the Cass review

Cass was told that patients were not always informed of “the irreversibility of some of the effects” of treatment. Some clinicians told her they were concerned that their colleagues failed to correct or challenge patients’ “magical thinking”, “ie unrealistic beliefs about what could achieved through medical transition”, she wrote in the letter sent in May and published on the NHS England website earlier this month.

Responding to these reports, NHS England has set out details of a new review, to be led by Dr David Levy, assessing “not only the quality (ie effectiveness, safety, and patient experience) and stability of each service, but also whether the existing service model is still appropriate for the patients it is caring for”.

Levy, a cancer specialist, who is medical director for Lancashire and South Cumbria integrated care board, will be supported by a panel of expert clinicians, patients and representatives from the Care Quality Commission.

NHS England has also published details of its plans to expand services for young people, increase workforce training, improve research, and explore providing support for patients who wish to reverse gender treatment and detransition.

Cass wrote that she had heard concern from some clinicians working in adult gender services that the approach to care was “ideologically driven and polarised and that it was difficult to question the approach or discuss concerns.

“A common concern was the very limited time for assessment and the expectation that patients would be put on hormones by their second visit,” she wrote. “The majority of patient presentations were extremely complex, with a mix of trauma, abuse, mental health diagnoses, past forensic history, ASD and ADHD, and therefore this limited assessment was inadequate.”

Concerns were raised “about the marked change in the case mix, from predominantly older birth-registered males to predominantly birth-registered females in their early 20s with complex presentations”, she wrote.

The Cass report into children’s services, published in April, recommended “follow-through services” for 17 to 25-year-olds, to avoid young people being transferred straight into a radically different adult services model.

The Cass report was welcomed by both Labour and the Conservatives, and NHS England on publication. However the British Medical Association last month voted in favour of a motion criticising the review and called for a pause to the implementation of its recommendations.

A spokesperson for the Cass Review defended its research standards.