Cass Review – implications for Scotland: findings report

Cass Review – Implications for Scotland

“A compassionate and kind society remembers that there are real children, young people, families, carers and clinicians behind the headlines.”

Cass Review Final Report (10 April 2024)

Introduction

“A compassionate and kind society remembers that there are real children, young people, families, carers and clinicians behind the headlines.”

It is recognised and acknowledged that the wider societal debate on gender identity is complex, with a range of opinions and concerns. The Cass Review describes the need to ensure an approach to gender identity healthcare that is more closely aligned with recognised NHS clinical practice, with a multidisciplinary team (MDT) focusing holistically on the needs of the child or young person.

These over-riding priorities are central to how we have developed our recommendations to the Scottish Government in response to the Cass Review. More than that, gender identity healthcare is not confined to services provided by a gender identity clinic. The responsibility for the full range of services in Scotland for children and young people with gender incongruence and dysphoria must extend beyond specialist services.

Background

The Independent Review of Gender Identity Services for Children and Young People, commissioned by NHS England, chaired by Dr Hilary Cass, was established in 2020 to make recommendations on how to improve NHS England commissioned gender identity services for children and young people. Its final report was published on 10 April 2024, accompanied by the publication of several systematic literature reviews conducted to inform the Review and the views of key stakeholders.

Clinical recommendations about the care of people, of any age and developmental stage, should be made carefully, and based on the best evidence available. The development of clinical pathways requires the gathering and interpreting of information, and then integrating it into informed decisions about the overall approach to clinical care. It is underpinned by experience, knowledge, collaboration, and evidence-based practice with the purpose of ensuring care is both effective and safe. This is core to holistic person-centred care, a human rights-based approach and informed decision making.

This approach is rooted in the principles and values of Scotland’s 'Getting it right for every child' (GIRFEC). GIRFEC places children and young people, with their families, at the heart of decision making and ensures a single, shared, rights-based approach to planning for their wellbeing. It also recognises the need for care to be adaptable enough to respect the views of a child or young person, their stage of development and the potential complexity of their life circumstances.

This also echoes the principles set out in the Chief Medical Officer’s (CMO) Realistic Medicine strategy. This aims to promote shared decision making between health professionals and individuals and to provide a personalised approach through inclusive communication to reduce harm and promote joined-up care that better meets an individual’s needs and preferences.

The foci of this report are the recommendations made by Dr Cass. This report does not seek to undertake a similar review in Scotland nor to provide a critical analysis of the Cass Review and the associated evidence. The intention of this report is to frame the Scottish Government's response to the Cass Review through a clinical lens and from a Scottish NHS context to ensure that the services provided in Scotland have children and young people at their centre.

We have applied a ‘systems thinking’ methodology to engage with key stakeholders to test and build a shared understanding of the current care pathway for children and young people with gender identity issues to ensure our recommendations are person-centred, coherent, and likely to succeed. This is in recognition of the fact that if one part of the pathway is adapted, we are likely to affect another part of it indirectly or directly. The stakeholders who have provided contextual information and views are detailed in Annexes A and B.

We are conscious that although we have heard from members of the trans community and their families, we have not directly sought lived experience perspectives as the remit of this group was not an open consultation. We have, however, reviewed the results of a range of lived experience consultations that have taken place as part of ongoing national work in Scotland to improve gender identity healthcare.

We would underline that we believe that the development of gender identity services in Scotland in response to this report should be developed with children, young people and their families in an active process of co-production.

We have concentrated on the healthcare provided for children and young people seeking help for gender-related distress. The report also considers how all services provided by the NHS in Scotland are supportive and respectful of children and young people’s gender identity.

It is worth highlighting that some of the recommendations in this report are equally applicable to other areas of highly specialist care where the evidence is emergent and where there is a need to ensure appropriate governance is in place to ensure that both those receiving care and those delivering it are fully supported.

It should also be noted that the process of consent in this context is complex and multifaceted and should not be viewed through a more simplistic treatment lens but rather with the support of the MDT and with a more careful approach.

Finally, there has been significant public, media, and political interest in gender identity healthcare provision for children and young people. We recognise that this may detract from the primary issue of providing the best clinical care necessary for them.

In responding to the Cass Review, we have aimed to stay strictly within clinical boundaries whilst recognising that at the centre of all this we have a responsibility to make sure that children and young people in Scotland grow up safe, respected and supported.

Professor Graham Ellis, Deputy Chief Medical Officer

Professor Alison Strath, Chief Pharmaceutical Officer

Dr Edward Doyle, Senior Medical Officer (Paediatrics)

Professor Justine Craig, Chief Midwifery Officer (Maternity, Neonatal, Children and Women’s Health)

Dr Aileen Blower, Psychiatry Advisor (CAMHS)