Health, Social Care and Sport Committee [Draft]

Meeting date: Tuesday, May 7, 2024

Official Report 774KB pdf

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Gender Identity Services for Children and Young People

Agenda item 2 is an evidence-taking session with Dr Hilary Cass on her review of gender identity services for children and young people, which was commissioned by NHS England.

Dr Cass, the chair of the Cass review, is joining us remotely and I welcome her to the committee. We will move straight to questions, Dr Cass. Thank you for your time.

I call Ruth Maguire.

Good morning, Dr Cass. Thank you for being with us this morning. Your review is obviously a detailed piece of work that needs careful consideration. We all appreciate that it is based on services in England, but it will have implications for how children are treated in Scotland, too. There is learning for all of us in it. Can you start off by talking about the key conclusions in your work that you would want us in Scotland to draw from to do the best for children in distress?

Yes. As will be clear from the report, the main concern for me was the weakness of the evidence base across all aspects of care. The critical issue is the need to work collaboratively as broadly as we can, both nationally and internationally, to try to improve that evidence base.

The second piece of learning from England was that, first of all, children were being bypassed, because they were not getting basic assessments locally; often they were bypassed straight through to the gender identity development service at Tavistock. Crucially—and this point is, I think, transferable—these young people need a very broad multidisciplinary approach to care, because they often have complex presentations, and just seeing them through a gender lens means that they do not get the breadth of care that they need.

I think that those are the two messages that apply, regardless of where in the UK or internationally you are.

Thank you—that was helpful.

Good morning, Dr Cass. Is there, in the 32 recommendations in what is a very comprehensive report, anything specific in relation to the delivery of services that you believe could apply in a Scottish context?

I would highlight some of the things that I have just alluded to. In England, in particular, we are embedding these services within a broader children’s hospital service setting to ensure that young people with autism, eating disorders and a range of other presentations have access to services, so that they get looked at holistically.

Moreover, with regard to the research and the clinical approach, which is going to be regionalised, there is, should the Scottish Government and the health service feel that it would be helpful, scope to include Scotland within the research infrastructure that we are setting up in England and in the regional network, where there is the ability to share and support clinical practice. Clearly, that is a decision to be made in Scotland; it is certainly something that I think we would welcome in England.

I turn to my second question. In your answer to Ruth Maguire’s question, you talked about the importance of the evidence base and collaboration. How do you feel about the fact that certain factions of the Scottish Green Party have said that your work is a “social murder charter”?

I think that it is not for me to comment on any political opinion in Scotland. My job is just to comment on the evidence as I see it, but if those opinions were to be framed into specific questions or concerns about my conclusions or the work, I would be happy to answer them.

Dr Cass, what key conclusions in relation to future provision for gender services would you want practitioners in Scotland to draw from the review?

It is important that young people get a holistic assessment. That includes looking at all aspects of their presentation and trying to understand their gender questioning in the context of other issues that are happening for them. One of the problems in focusing only on gender is that you can end up putting somebody on an endocrine pathway when you have not addressed the fact that they have undiagnosed autism, they are out of school, they are not participating or there is family breakdown—all those other factors.

It is about seeing them as a young person first and understanding the gender distress through that lens, and, I think, accepting that two things are simultaneously true: first, that a small number of these young people will benefit from a medical pathway for their gender distress; and, equally, that for probably a larger number their gender distress will be resolved in myriad other ways—whether that is that it has been a developmental questioning period that spontaneously resolves, whether they resolve uncertainty about their sexuality and then their gender questioning resolves or whether they find that they do not want a very rigid medical pathway but just remain gender fluid or gender non-conforming in the longer term.

It is about being open, exploring and making sure that options are not foreclosed too soon for that young person. That is probably the single most important takeaway.

Thank you for that answer.

Good morning, Dr Cass, and thank you for spending some time with us this morning.

You rightly mention that the evidence base is a hugely important part of the work that you have undertaken, and that has clearly gained traction in the discourse following your report. Will you talk through the approach that was taken in assessing that evidence, including the systematic review methodology, what evidence was included and what was not included as part of that assessment and why?

The systematic review was carried out by the University of York, which is one of a small number of organisations that are commissioned by the national health service to carry out systematic reviews. It was overseen by the head of that department. It looked at a very wide array of papers—well in excess of 200 across all areas—but the papers that have got most attention are the ones that focus on puberty blockers and masculinising and feminising hormones; 102 papers were included in that search.

There has been significant misinformation about those papers. I hope that that has now been corrected in everyone’s minds but, to be clear, incorrect information was being circulated that indicated that 98 per cent of the papers had been disregarded and that only randomised controlled trials were included. Both of those things are wrong. There were no randomised controlled trials. Two high-quality papers and more than 50 moderate-quality papers were used. Overall, 58 per cent of the 102 papers were included in the analysis, because they were of high or moderate quality. Those papers included a variety of different studies, mainly cohort studies, which follow up and compare groups or look longitudinally. Those studies are not randomised controlled trials, but they are still accepted as good evidence if they are conducted well.

The significant weaknesses in most of the literature—I apologise; I have a frog in my throat—was that the follow-up periods were not long enough; that there was significant loss to follow-up, so the studies started off with a larger sample and, because significant numbers dropped out during the course of the study, that made it hard to draw conclusions; and that the comparison groups were not appropriate. The literature was very poor in comparison to most other literature, including in children’s healthcare practice—that was quite striking. The evidence for the efficacy of puberty blockers and masculinising and feminising hormones was weak. We are still unclear about the potential adverse effects of that. I can say a bit more about puberty blockers if the committee would like me to, because that has been a source of contention.

We will come on to that in follow-up questions.

You have answered some of my supplementary questions as well. You have said, first, that the supposed statistic that 98 per cent of the evidence should be ignored is wrong and, secondly, that the evidence that was not included—it sounds as though that was a bit less than half of it—was not included because the methodological approach was not robust enough for the University of York’s work. I was also going to ask how it compares to methodologies that are applied in other areas of paediatric medicine, but I think that you have answered that by saying that it falls significantly short of the literature that you would see in other areas.

I will move on to ask you about how we fill those gaps. What research is under way at the moment? Is it sufficient, and what else needs to be done? How long will it take for us to build an evidence base that allows us to address these questions more robustly?

I will address the last point. There has been a question of whether we have set a higher bar for the research and our systematic review—we absolutely have not. These young people should get the same standard of evidence in their care as every other young person; that is the bar that we should set.

In England, a puberty blocker trial is being designed that will obviously involve service users. The lead investigator has been appointed and a group has started to come together to think about it. There will potentially be some international collaboration on that. I feel that we need every young person who walks through the door to, ideally, agree to be part of some kind of study and follow-up process, because it is just as important for us to understand what happens to the young people who do not go on a medical pathway as it is for us to understand what happens to those who do.

We need to understand what aspects of care, both medical and non-medical, have been helpful for the whole group. That would mean following young people into adulthood, including those who go on a medical pathway. Obviously, we cannot compel anybody to be followed up into adulthood and a lot of it is about rebuilding trust with young people so that they wish to be part of a study into adulthood to help the young people who are coming behind them.

09:15  

That is great, thank you. Just to be clear, what questions would you hope that the research and future evidence would give us the answers to?

We want to understand whether there is a small group of young people who do benefit from puberty blockers; we also want to understand what potential negative effects there might be on that, particularly for broader brain development and psychosexual and psychosocial development, as well as bone health and other physical health indicators. We want to understand more about which young people may benefit in the longer term from going on to masculinising or feminising hormones.

The real challenge is that young people’s sense of self and gender identity continues to evolve into young adulthood and we do not have an accurate way of predicting who will have a long-term stable trans identity. The more we are able to be really clear about who has a successful long-term outcome and who has an outcome that does not meet their aspirations, the better our understanding will be.

We also need to understand what things matter in the longer term to these young people. It is not just about whether someone can successfully achieve a medical transition—we know that we can do that—but about how they are doing in the longer term. Are they participating—do they have a job, do they have a partner, are they happy with their sex life, are they happy, are they psychologically well? All those things are important.

So it would be about looking at physical and mental outcomes from a health perspective.

Yes—and social outcomes.

And that research would look at people who chose to detransition at a future stage as well.

Yes, and there has been anxiety about that. The trans community has been concerned that we are looking at detransitioners to say that we should not be giving gender-affirming care, but the important thing is to understand what factors led people to detransition. Were there earlier signs that it may not have been a successful pathway for them? You can then build those things into the equation and discuss them with somebody coming through so that they know what the likely risks are for them as an individual.

It is the same as any medical intervention, where you look at somebody who has a less successful outcome and then explain that to people who want to undergo the same procedure to inform them about it. It is not about telling them that they cannot do it; it is about saying that these are the risks that we are aware of.

That is great—thank you very much.

Good morning, Dr Cass. Thank you for being here this morning. I am interested in the recommendation that young people should remain within the young people’s service from the age of 17 to the age of 25. The recommendation says that NHS England should ensure that each regional centre has

“follow-through services for 17-25-year-olds ... either by extending the range of the regional children and young people’s service or through linked services”.

I am interested in hearing about how that recommendation means that those young people should stay under the care of the same service from the age of 17 to the age of 25 and how that would work in practice. I think that there has been some misrepresentation of the recommendation as meaning that no one would be able to transition before the age of 25.

Yes, there has been a lot of misunderstanding about that recommendation as well, as you rightly say. We proposed it because it is in line with other aspirations that NHS England has for longer-term services for young people, including in the areas of mental health and cancer. It is about continuity of care.

The worst possible time to transfer services is when you are at a critical point in your gender transition, at around 17 to 18. We know that that is a high-risk time, when young people get lost between children’s and adult services. There are problems in managing their medication through that period, and switching care providers is challenging. We also lose data at that time, which is an important issue if we are trying to get better long-term data.

The idea is to provide continuity for the young people who are already in the service. If you are already over 18 when you are referred, you would still be referred to existing services; you would not come through that follow-through service. At the moment, it is specifically being set up to take people who started when they were younger to give that continuity of clinical care and follow-up data.

I want to pick up on what you said about the misrepresentation of that recommendation or other parts of the report. You talked about a holistic assessment for young people for the whole process. One of the comments that have been made is that the recommendation is based on “dubious science”. Can you solidify for us your advice or your recommendation around having a whole process for young people right up until the age of 25?

Sorry, but is the bit that you think has been said to be based on dubious science about having a holistic assessment?

It is really about the wider recommendation on supporting young people right through the process. The information that we have says that it has been said to be based on dubious science. I would be interested to hear how that is one of the misrepresentations of the report.

The misrepresentation was that, when we said that young people would not have to transition at that vulnerable time, we meant transition between services, and that was taken to mean that they would not have to make a gender transition at that vulnerable time. That was a misreading, because the term “transition” is used to describe the move from children’s to adult care, as well as gender transition. It was taken to mean that we were saying that children should not go through a gender transition at that time, but that was not what we were saying. I think that the point came in a section headed “Service Transition”, so that was a misreading.

I do not know whether that helps.

It does help, actually—it shows the power of correct words. Thank you.

I declare an interest as a practising NHS general practitioner.

Thank you for joining us, Dr Cass. I have grave concerns about the use of puberty blockers for children, given the paucity of evidence and given that the early intervention study did not demonstrate benefit. I feel that ideology and dogma have no place in medical treatment. Given that you have stated that young people’s gender identity is “fluid” and that there is “no hierarchy”, do you feel that there is an age where it becomes more fixed?

A study was released around the time that the report was in press that showed that gender discontentedness was relatively high from age 11 and continued to drop sequentially into the early 20s. It is really difficult to know the exact sweet spot when somebody’s gender identity is not going to continue to change and the best time to commence an irreversible treatment.

We were quite struck by young adults whom we spoke to as part of the engagement process and also through our qualitative research saying that they wished they had known that there were more ways to be trans than just via a binary medical transition and that one could be more fluid without necessarily having to go down a medical pathway, although some people will do that. They said that their main advice to their younger selves would be that this is not urgent and you do not have to rush, although they acknowledged that it feels urgent and that their younger selves probably would not have taken too much notice of their older selves. It is the dilemma that we all face.

Certainly, the things that I believed when I was a child are very different from the things that I believe now, as are the things that I feel are or are not important.

In your report, recommendation 8 states that we should be looking to prescribe medication at 18, and recommendation 6 states that we need a trial. If medication were to be given below the age of 18, would it be appropriate for that to happen without parents’ knowledge, or do you feel that 18 is the right point? Also, given your previous statement, why did recommendation 8 state 18 as the age?

My remit does not extend beyond 18, and, as you know, a young person is considered to have capacity at 16, unless we have good reason to think that they do not. Therefore, as far as capacity is concerned, it is hard to make a legal distinction between a 16-year-old and an 18-year-old.

When I thought about consent, I considered that the challenge is not so much about capacity but about other elements, one of which is clinical judgment with regard to offering a treatment. As you know, we all bear responsibility for the treatments that we offer and for knowing whether a treatment is the right one for an individual. Another element is the information about risks and benefits that we give to inform consent; again, that is weak. Legal cases have obviously focused on competence and capacity, but those are the other challenges—the two pillars of knowing whether we are giving the right treatment to the right people.

Gillick competence can mean from the age of 13 onwards, which is why I asked about parents, too. Can we use Gillick competence in this treatment pathway, and, if we can, should the parents be aware?

The Tavistock avoided treating without parental consent and engagement, and everything that we know about outcomes in young people is that they thrive better with family support. I would have severe reservations about any child being put on this kind of pathway without a competent adult supporting the decision. The Dutch protocol, which the Tavistock was supposed to be adhering to in its service specification, specified parental support for such decisions, and I think that that should stand.

I have major concerns about private treatment. Throughout your report, you talk about a multidisciplinary team approach; it is, in fact, mentioned in recommendation 9. In that case, should a single private practitioner be prescribing medication? Is it appropriate for that to occur?

Like you, I have really deep concerns about private provision de facto; based on the recommendations that we have made, it will not meet the standard. I feel that it would put young people at considerable risk not to have the level of assessment that we are describing.

09:30  

I have a final question, Dr Cass, if I may. An important area is regret and detransitioning. What does your research show about the number of children who experience regret? Indeed, has it been able to show that? You have said that puberty blockers are irreversible, so what do we then do with children who face that issue?

What we know to be irreversible are some of the effects of the masculinising and feminising hormones. We do not know the percentage of people who detransition or feel regret, largely because the follow-up has not been long enough and also because those who detransition or regret do not necessarily come back to the NHS and—[Interruption.] Excuse me—I think that I have a frog in my throat this morning. Often they do not come back to the clinic from which they originated, and it is a significant problem.

That said, I think that it is more subtle than that; for example, I spoke to a young adult who started transition very early from male to female. She is doing well—she had puberty blockers and feminising hormones at the earliest stage, and she passes very well as a woman—but with hindsight, she knows that she was a boy with intense internalised homophobia and was gay. At this point in her life, she is clearly not going to detransition, so she would not show up in regret or detransition data, but she thinks that it was maybe not the right decision to have made.

There will be people living a good life but who might, with hindsight, have made a different decision—that sort of thing is much more subtle. There are also people who are living their best life having gone through a medical transition, and for them, the costs and side effects of treatment are worth while compared to what it would have been like to have had to live their lives within their birth-registered gender. It is really difficult for us to get under the skin of those sorts of subtleties.

Good morning, Dr Cass. Do you believe, and does your research show, that puberty blockers or gender-affirming hormones could be the right intervention for some children or young people?

We think that masculinising and feminising hormones could certainly be the right treatment for some young people, but we do not know which young people those would be. In the case of puberty blockers, it is much less clear what the indication is. Would the convener like me to say something about what we do and do not know about puberty blockers and the various indications?

Yes, please.

To start with, we need to look at why puberty blockers were introduced. Previously, you would not start on a medical pathway until you were 16-plus. The consultant who moved into the Dutch clinic had seen poor outcomes in adult patients and felt that one of the reasons for that was that they were not passing, and that was having adverse psychological effects. Therefore, she reasoned that if you blocked puberty early on, you would not get the irreversible pubertal changes that birth-registered males get—that is, the facial hair, the voice dropping and so on—and which will always make it hard for you to pass. Secondly, she reasoned that it would buy time for people to think.

Going through those indications, I see no evidence that it does buy time to think, in that the vast majority of those who take puberty blockers then go on to masculinising and feminising hormones. It might be that it alters the trajectory and makes it less likely that, once you start, you will reconsider the options, because you have not gone through your own puberty or through that psychosexual development pathway.

The other aspects that have been looked at are whether they improve your body image and whether they make you less dysphoric. Nobody—not even the original Dutch study—has shown those things to be the case. The other question is: do they improve your psychological wellbeing? Although the original Dutch study found some weak evidence of that, the English study did not replicate that. Indeed, no other study really has, either.

That leaves us with one specific indication, which is that they might be helpful, particularly for birth-registered males in preventing those irreversible changes. However, one of the downsides of the focus on puberty blockers, which have become almost totemic as the way to get on to a treatment pathway, is that it has stopped us looking at other ways of managing young people’s distress when they are working out the right pathway for them. As a result, we have not looked at known evidence-based treatments for anxiety and depression such as psychological support or medications for anxiety and depression that might be just as or more effective than puberty blockers. It is all about being really clear about what they are for and for whom.

A range of trans organisations and people have said that the report’s recommendations and the narrative surrounding it give the impression that transition would be the worst outcome for a young person. How would you respond to people who get that impression from the report?

For somebody who is going to have an enduring long-term trans identity, medical transition is an important option and one from which many people benefit. The risk of starting that transition at a time when somebody is still developmentally labile—that is, still in the process of development—is that you give the treatment to the wrong group of people. That is a negative outcome, because medical transition does not come without costs to effect on sexual function and fertility, and there are knowns and unknowns in relation to long-term bone-health risk and the limitations of surgery.

All of those costs are well worth while if you have a long-term stable trans identity, but it is a high cost to pay if, in the longer term, you do not, and it is, as I have said, very important to find that sweet point where you have a high level of certainty that you are giving the treatment to the right people. The group that we have least understanding of is the group that we are most commonly seeing now in clinic, which is birth-registered females presenting in adolescence, for whom a range of other factors might be driving their gender-related distress.

Thank you. I have a final question. You have mentioned research in your other answers. What, in your view, does good research look like in this area, and do you think that it is important that trans and non-binary people are involved in all stages in co-producing it?

The answer to the second question is a straightforward yes. That is clearly built into any good research, and it will be built into this. However, we need well-designed studies with adequate follow-up and clear comparisons with other kinds of treatment options. That is what has been lacking from previous research. The team is already thinking about the most ethical and acceptable ways of doing that, and there will be very careful engagement with service users.

Thank you, Dr Cass, for your contribution so far. I want to look at the wider balance of harms. We have noted that the average wait from referral to being seen at a gender dysphoria clinic can often be more than four years. During that time, people may experience significant distress—physical, psychological and social—and they may self-medicate with hormone replacement drugs, although I am not sure how accessible puberty blockers are. Obviously, that can introduce unregulated harms beyond, say, the practice of bridging prescriptions. What observations do you have and what evidence have you seen about that broader behaviour of self-medication?

We have not had any way of systematically understanding how much of that goes on but, clearly, it happens way more than we would wish.

As we all understand, that is driven by major shortfalls in children’s mental health services. Young people are in a state of distress and anxiety. Often, they get no support for that or for any other aspect of their presenting problem, and advice is available only from the internet or from peer support groups. It is therefore inevitable that they will take actions that we would deem to be of higher risk. I can understand that, because, often, the care that is provided by the health system is failing them. That system failure is related to workforce and all sorts of other things.

Another big problem is fearfulness among healthcare practitioners. Those young people are more disadvantaged than other similarly distressed young people—certainly in England—because people have been bypassing them. When somebody says that they are gender questioning, health professionals feel nervous, because they do not think that they have the necessary skills, and they are worried about the toxicity of the debate and about doing or saying the wrong thing, so they pass them straight through to the GIDS waiting list. Consequently, those aspects that they would have been able to manage, because they have all the skills to do so, are not treated.

Do you have any thoughts about how best to remedy that?

That is starting already, in the new centres in England. There has been concern about starting that new service, but now that practitioners have started seeing young people, they are clear that those are the same young people that they see in other clinics.

It is about building confidence. When I was the registrar for the Royal College of Paediatrics and Child Health, some 15-plus years ago, we were really worried that we would not be able to recruit paediatricians, because people were so scared about safeguarding. It was catastrophic if you made an error in either direction—overdiagnosis or underdiagnosis—the research was poor, there were no guidelines and there was little training. We remedied that with much better research, much better guidance and really clear training and supervision. That turned things around and it became an interesting area of practice. That is what we want to achieve.

As I said, a lot of it is about building confidence, because professionals have the transferable skills and they just need to know that those are the same young people, with the same hopes, aspirations and anxieties as most of the rest of the people in their clinics.

Dr Cass, in your response to Paul Sweeney when he asked about unregulated access to hormonal treatment or to puberty blockers, have I picked up correctly that you were saying that it is happening way more than we would wish that children and young people are accessing those medications in an unregulated way?

09:45  

Yes.

Thank you. I was just seeking clarity on that point. I call Ivan McKee.

I have covered all the issues on research follow-up when I asked questions earlier.

We move to Carol Mochan.

Dr Cass, I want to explore the approaches to gender care for young people and the move to what you have described as the gender-affirmative model, which is the dominant model of care. You have talked about clinicians feeling pressure to simply affirm children and that that could lead to diagnostic overshadowing; for example, you have spoken about mental health issues that have been missed. How would a conversion therapy ban affect that situation? Could you advise how we might go forward with a ban to ensure that we give children protected time to consider things?

That is a big challenge. All that I can say is that I am glad that I am a doctor and not a litigator, because it is a really difficult problem.

Everyone should be protected from conversion therapy. It is a completely unacceptable practice. In thinking about legislation, however, the issue has been intent. If a therapist engages with a young person and that young person changes their views about their gender identity during that therapeutic relationship and they subsequently say that that was because the therapist had an intent to change their gender identity, that puts the therapist in a difficult position, because how can someone legally determine intent? The anxiety that they might become the test case for that is making clinicians even more anxious about working in this area, and we do not want to do anything to frighten off professionals from working in it. Walking that path is very difficult.

The only thing that I would say is that no credible professional body would support conversion therapy so if any practitioner is deemed to be practising conversion therapy, that should, in the first instance, be a matter for their professional regulator before it would be a legislative issue.

However, I do not know how we get that balance right of protecting people from conversion therapy and not frightening therapists who are just doing their job by having an appropriate exploratory conversation with a young person.

Thank you. That is one of the issues that we need to get right for both clinicians and young people.

I wonder if you could you give us a little information. One thing that has interested us is people presenting at the clinics who are same-sex attracted and how we make sure that there is that space for those young people. You mentioned a case earlier in which a person reflected on what had happened to them in that regard. If I put that issue in the context of a conversion therapy bill, do you think that we need to take that apart and look at having a bill that deals with conversion therapy in relation to same-sex attraction and trans identity? Should we consider doing that?

I think that we need to. A very high percentage of these young people are same-sex attracted, so you can see how the two things could get conflated.

It might have been naive, but one aspect that I was surprised about when I was conducting the review was how much homophobia and transphobia still exist. We have to support people to enable them to express and understand their sexuality as well as their gender identity.

My final question is on a point that was raised with the committee, which was about including someone with trans identity in the review team. Did you consider doing that?

I am sorry; could you say that again?

Why were no trans people included in the review team?

The review team was very small—there were only four or five people in it. We did not specifically exclude trans people from the team, but none applied. It is hard for a person on a team to be what might be seen as a tokenistic representative of the whole community.

However, we ensured that we had wide engagement. Every four to six weeks, we spoke to the main trans advocacy groups. We also had listening sessions with service users, 18 focus groups with young people, round-table meetings with support and advocacy groups, and qualitative research that took account of both young people’s and young adults’ experiences. Further, we consulted internationally. Therefore, we made every effort to incorporate service users’ voices as broadly as we could.

That is really helpful. Thank you very much.

Dr Cass, I wonder if I could go back a little. You spoke about professionals’ fearfulness of discussing this area. In answer to my colleague Carol Mochan’s questions on conversion and on professionals having space to explore options with children and young people, you said that research, guidance, training and supervision were the answers. Do you want to add anything further? I know that you will have had personal experience of the heat and noise that surround this topic.

One of the challenging aspects for the Tavistock and the GIDS is that they were a single provider. It is difficult whenever there is a single provider that is not peer reviewed, and which does not have the ability to share practice with other centres. That is why we are setting things up in England so that there is a single national provider collaborative, in which such centres can come together, as an overarching structure, to support all the regional centres. The idea is that it does not matter whether someone walks into a service in Birmingham, London, Newcastle or wherever else; they will get the same standards of care and the same decision making. That also means that clinical guidance and training can be shared, the research works across the sector and, importantly, those centres can share data, through a shared data set that works across them all. That was why I said that if there were to be interest from Scotland in a centre here becoming a regional one, that might work, although it might not be physically close. I cannot speak for NHS England or about the formal governance of such an arrangement, but I am sure that the prospect of being able to share practice would be welcomed on both sides.

Dr Cass, I know that adult services were outside the scope of your review, but you mentioned them in your report. At paragraph 19.31, you stated:

“There was an expectation that patients would be started on masculinising/feminising hormones by their second appointment, which was a cause of concern given the complexity of presentations.”

Did your research show anything similar for children’s services?

I know that, in the past, some children and young people have started on treatment relatively quickly. There was variability across the various teams within the GIDS, but that was certainly not supposed to be the way that things operated. Certainly at the latter stage, there was more careful control to make sure that it did not happen.

A number of people from adult services spoke to me about their concerns, and that comment was part of their feedback to me. Given that they were seeing the same sorts of young people moving through, with the same complexities of presentation, they had clinical concerns about having to make such decisions so quickly.

Good morning, Dr Cass. I want to pick up on a couple of areas that have already been discussed. The first is about the cohort of patients. The data shows a huge and quick increase in birth-registered females, the majority of whom are same-sex attracted. That is a very different cohort from the one that was considered in the earlier studies. Also, the new cohort’s presentation is much more complex. You have suggested that care should routinely include, for instance, screening for neurodevelopmental conditions. Will you tell us a little bit more about the change in the cohort, the extent to which treatments had been based on the previous one, and the potential risks around that?

You have summarised it exactly. As I said, the existing research on the previous cohort is weak, and that on the current cohort is even more limited, so we cannot make any assumptions that the original puberty blocker studies can be read across to this group.

It is important that we consider the newer presenting group in the context of what is happening to adolescents in gen Z more widely. We know that there are high rates of depression and anxiety among them. They have stresses that previous generations did not have when they were growing up, in the form of social media and the expectations on young people that arise from early exposure to pornography. We do not understand what any of those factors might do to how their distress might be presented. For some young people, such distress, or the feeling that they do not fit what they perceive to be the expected gender norms, might manifest itself through questioning their gender identity. That is why we really have to take this as a new cohort, not rely on the previous research, and work with young people to help them to unpick all the factors that might have led to such gender distress.

One aspect that has been somewhat lost in the debate is that there is a really close mind-body interaction—in the relationship between mental health and how people physically manifest it. Unpacking that is really complex and difficult, and it has to be done very carefully.

Thank you. I have a question on detransitioners, if I may.

We must close, I am afraid. We need to finish this part of the meeting by 10 o’clock.

Thank you for your attendance, Dr Cass, and for the information that you have given to the committee. I am sure that it will help us in our further inquiries when we have other interested parties along to speak to us in the coming weeks. Thank you for your time.

09:59 Meeting suspended.  

10:06 On resuming—