THE FINAL REPORT of the Cass Review was published last week after four years of work by a vast team of people working under the leadership of Dr Hilary Cass to try to bring clarity to this very important if sometimes contentious area of healthcare.
The aim of this work was to find out how best to help children who don’t identify with the sex they were born with or have other difficulty with their bodies and gender role. I was delighted and honoured to be invited to be part of this team and I thoroughly enjoyed collaborating with the dedicated and open-minded experts Dr Cass had assembled. The extent of inclusion of service users and others with lived experience in this review was unparalleled.
The Cass report is the most comprehensive review of available evidence, experience and expertise ever conducted. There was extensive inclusion of the lived experience of patients and families and inclusion of gender advocates and support groups. A wide range of professional expertise was involved including both gender specialists and other clinicians.
Most important was the analysis of all available published and unpublished research and audit evidence. The detail, rigour and transparency of this review process means that few people will read the entire report, however, I would like to highlight the key findings and recommendations that apply to Ireland.
Perhaps the most important issue identified at the outset is the lack of high-quality evidence in this area. This echoes the findings of other recent international reviews including the systematic review published by the Swedish government last year and that published by the German government earlier this year.
The quality of research that has been published in peer reviewed journals in this area is truly appalling and would never be accepted in other areas of medicine.
It is this poor research which has fostered unsafe services and treatments for children, and the need now for proper research evidence is clear.
While Cass acknowledged the weakness of the evidence in general, it found there was sufficient evidence to make some clear findings, something the Irish government should take heed of.
The first is the use of puberty blockers in children; the so-called Dutch Protocol which was given to Irish children despite the fact that the results from the early intervention study in 2015-2016 did not demonstrate benefit. The results of the study published in 2020 showed there was a lack of any positive measurable outcomes from the Protocol.
The studies found no changes in gender dysphoria or body satisfaction, no evidence that puberty blockers bought time to think, but there were risks of harm to psychosocial wellbeing and cognitive development, and bone density was compromised. Many of these children went on to have cross sex hormone treatment and some are now infertile.
Despite this evidence, as well as the warnings from the clinicians at the National Gender Service and the UK government and independent investigations, the HSE continued to give Irish children this unsafe treatment and when the UK government shut down the unfit Tavistock, the HSE set up a new arrangement with a private clinic in Belgium to do the same thing, which is still going on. This must be stopped immediately.
Another important finding is the lack of evidence supporting the World Professional Association of Transgender Healthcare guidelines, WPATH SOC8. While highly influential, and supported by activists, its guidelines were found by the University of York appraisal process, as part of the Cass review, to lack developmental rigour.
The National Gender Service had advised the government as early as 2018 that these guidelines were unsafe and unsuitable. Despite this, WPATH SOC8 have been included in the Programme for Government.
The Programme for Government does not contain clinical guidelines for other areas of medicine. The Cass Review could only recommend two guidelines for practice – the Finnish guideline published in 2020 and the Swedish guideline published in 2022. Clearly, the Irish government needs to remove the WPATH guidelines from the programme for government and instead adopt the Cass Report as the key policy document.
The Cass review sets out a comprehensive framework for the development of good gender healthcare services for children. One of the key recommendations is that there should be a nominated medical practitioner (paediatrician/child psychiatrist) who takes overall clinical responsibility.
This means that while we need to try to deliver as much care in a community setting as possible, the idea of GP or psychology-led gender healthcare service is out.
The Review also identified the need for screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment, because of the complex needs of these children.
There needs to be Multi-Disciplinary Teams (MDTs) with specialist skills in neurodiversity embedded in gender healthcare and not just for screening, but also for delivering therapeutic interventions as well. The lack of services for neurodiverse people is one of the greatest shortcomings of the Irish health service.
The Cass report also highlights the dangers of private gender healthcare which is also rampant in Ireland. The four main issues around private gender healthcare are the potential for conflict of interest, more limited assessment, a lack of regulation and a narrow focus on gender-only issues without the broader MDTs to address the other problems these children have.
There is an inherent conflict of interest involved in providing gender healthcare privately. Where time is money, the extended assessments many children need are not possible, and online, remote assessments are more prevalent in private gender services which in my view, gives a lower quality of clinical assessment in these cases.
HIQA regulates public health services, but there is no equivalent statutory body to regulate private healthcare. The Cass Report has called on the UK government to examine the implications of private healthcare, and I believe the Irish government should also take measures to protect Irish children from any potential issues.
As well as private gender healthcare provided in Ireland, there is even more dangerous healthcare being delivered or directed from outside the State. Sometimes they send the drugs directly to Irish children and sometimes they instruct the Irish GPs to prescribe drugs for children. The Cass Review found that GPs had expressed concern about being pressurised to prescribe hormones after these had been initiated by private providers.
The National Gender Service has also received requests for advice from many Irish GPs who are in this position. We advise against getting involved in shared-care arrangements with private providers who are unregulated and outside the country, but there should be clearer guidance about this from the ICGP and the Medical Council.
Irish pharmacies should also take a more responsible position about dispensing foreign hormone prescriptions. The Cass Report recommends that the UK Department of Health and Social Care should work with the General Pharmaceutical Council to define the dispensing responsibilities of pharmacists of private prescriptions and consider other statutory solutions that would prevent inappropriate overseas prescribing. Irish pharmacists too, should stop dispensing foreign gender healthcare hormone prescriptions.
The responsibility for supporting and keeping safe gender-incongruent children lies not just with the medical profession, but with all of society. We need all professionals and the public to be better informed. The Cass Review identifies a need for a separate pathway for pre-pubertal children and their families outside the gender healthcare system for adolescents and adults.
The Report recommends that when families/carers are making decisions about social transition of pre-pubertal children, they should be seen by a clinical professional with relevant experience. Dr Cass has identified that social transitioning is not a neutral action and is often the beginning of a clinical process.
Irish schools should not be taking the lead in the social transitioning of children. The Department of Health should reconsider some of the overly affirmative educational and training materials it is sending to schools and the prominent role it has given to activist organisations in policy development and teacher training.
The publication of the Cass Report last week is the most important event in the development of gender healthcare globally to date. It is particularly timely for Ireland as we are embarking on a re-think and re-development of our gender healthcare services.
A new National Clinical Lead for the development of gender healthcare in Ireland has been appointed. Dr Karl Neff, a consultant endocrinologist, very experienced in gender healthcare, is due to take up the role imminently, and the work done by the Cass Review team will be of great relevance to the development of services here.
The National Gender Service, which currently provides care for people over 18, has proposed that its remit be extended downwards to provide a single, seamless service for adolescents and adults.
The Cass Review came to the same conclusion as the NGS, coming from the other end of the age spectrum. It has recommended follow-through services for 17-25-year-olds at each of the Regional Centres for adolescents, to ensure continuity of care and support at a potentially vulnerable stage in their journey.
Whatever new Model of Care is developed in Ireland, it is essential that the required resources are put in place by the Department of Health and the HSE to enable safe and timely services for gender non-conforming children and adults.
It is also time for Child and Adolescent Psychiatry in Ireland to step up and shoulder its responsibility. Due to a lack of leadership and engagement by relevant bodies, over many years, we have a vastly under-resourced service which has led to enormous waiting times.
We have a lot of catching up to do, but with the new National Clinical Lead and the Cass Report, we now have the leadership and the roadmap. Hopefully, this will be matched by HSE and government support to develop a world class gender healthcare system for Irish people of all ages.
Dr Paul Moran is Qualified in medicine RCSI 1987. He did higher specialist training in Gender Psychiatry at Guy’s Hospital London in 2001 and worked as consultant at St Columcille’s Hospital from 2002. He has provided care to transgender patients with Professor Donal O’Shea and developed the National Gender Service Model of Care with the HSE and St John of God & Mental Health division. He is a member of the Cass Review Clinical Expert Group of 2023.
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