The BMA has called for a pause to the implementation of the Cass review’s recommendations on treatment of transgender children.
The doctors’ union intends to undertake its own evaluation of the the independent report following ‘concerns’ voiced by doctors and academics, which it expects to complete towards the end of the year.
‘In the meantime, the BMA believes transgender and gender-diverse patients should continue to receive specialist healthcare, regardless of their age,’ it announced today.
Members of the BMA council voted in favour of a motion last week which asked the union to ‘publicly critique the Cass Review’.
The vote took place after doctors and academics ‘voiced concern about weaknesses in the methodologies used in the review’, and ‘problems arising from the implementation of some of the recommendations’, the BMA said.
The union added that there have been ‘ongoing discussions’ within the BMA about the Cass Review since it was published.
‘These, together with the council’s wishes, have helped to shape what will be a detailed, evidence-led piece of work,’ it said.
The Cass review’s report, published in April, concluded that for most young people a medical pathway may not be the best way to manage their gender-related distress.
An emergency ban on private prescribing of puberty blockers was implemented by the last Government after the review’s publication, and this decision was defended by health secretary Wes Streeting earlier this month.
But the BMA has been critical of banning puberty blocker prescribing to children and young people with gender dysphoria, calling instead ‘for more research to help form a solid evidence base for children’s care’.
BMA council chair Professor Banfield will now appoint a task and finish group to look at the review and make recommendations to improve the healthcare system for transgender children.
He commented: ‘It is vitally important we take time and care to get this work right. This is a highly specialised area of healthcare for children and young adults with complex needs, and as doctors we want to be sure they get the most appropriate care and the support they need.
‘The task and finish group will make recommendations to improve the healthcare system that has, for too long, failed transgender patients. It will work with patients to ensure the evaluation invokes the old adage in medicine of “no decision about me without me”.
‘It is time that we truly listen to this group of important, valued, and unfortunately often victimised people and, together, build a system in which they are finally provided with the care they deserve.’
The Cass review, which was published in April this year, found that children and young people seeking NHS care for gender-related distress have been let down by the ‘remarkably weak evidence base’ and an increasingly toxic public debate.
It concluded no clinician should be expected to prescribe outside of their competence and that GPs should not be expected to enter into a shared-care arrangement with a private provider, ‘particularly if that private provider is acting outside NHS guidance’.
In a detailed analysis of NHS gender services for those under the age of 18 years, paediatrician Dr Hilary Cass called for a more ‘holistic and personal’ approach with gender services matching the standards of care and research expected from other parts of the NHS.
The review was not about undermining the validity of trans identities but about determining the right healthcare approach for the growing number of children and young people looking for support with gender identity, Dr Cass said at the time.
Overview of the Cass Review recommendations
- Services must operate to the same standards as other services seeing children and young people with complex presentations and/or additional risk factors.
- Expand capacity through a distributed service model, based in paediatric services and with stronger links between secondary and specialist services.
- Children/ young people referred to NHS gender services must receive a holistic assessment of their needs to inform an individualised care plan. This should include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment.
- Standard evidence based psychological and psychopharmacological treatment approaches should be used to support the management of the associated distress from gender incongruence and cooccurring conditions, including support for parents/carers and siblings as appropriate.
- Services should establish a separate pathway for pre-pubertal children and their families. ensuring that they are prioritised for early discussion about how parents can best support their child in a balanced and non-judgemental way. When families/carers are making decisions about social transition of pre-pubertal children, services should ensure that they can be seen as early as possible by a clinical professional with relevant experience.
- NHS England should ensure that each Regional Centre has a follow-through service for 17–25-year-olds; either by extending the range of the regional children and young people’s service or through linked services, to ensure continuity of care and support at a potentially vulnerable stage in their journey. This will also allow clinical, and research follow up data to be collected.
- There needs to be provision for people considering detransition, recognising that they may not wish to re-engage with the services whose care they were previously under.
- A full programme of research should be established to look at the characteristics, interventions and outcomes of every young person presenting to the NHS gender services.
- The puberty blocker trial previously announced by NHS England should be part of a programme of research which also evaluates outcomes of psychosocial interventions and masculinising/ feminising hormones.
- The option to provide masculinising/feminising hormones from age 16 is available, but the Review recommends extreme caution. There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18. Every case considered for medical treatment should be discussed at a national Multi- Disciplinary Team (MDT).
- Implications of private healthcare on any future requests to the NHS for treatment, monitoring and/or involvement in research, and the dispensing responsibilities of pharmacists of private prescriptions needs to be clearly communicated.
Source: Cass Review
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READERS' COMMENTS [6]
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Such hormonal treatment and surgery is dangerous. Some want to detransition but have already come to irrevocable harm.
Cass has called for the prescription of puberty blockers to be available only in context of clinical trials. Cass suggests a significant risk of harms arising from their use in children with dysphoria.
My understanding is that the vast majority of peer review is in concordance with the review by Cass. It is now obvious from the details in Cass’s review, of the lack of rigour implementing this experimental treatment for children with gender dysphoria.
Unless the BMA has immediate and compelling evidence (which it should produce) that Cass’s methods or findings are unsafe or fatally flawed, it is premature to call for such a pause. It is also inappropriate that this motion has been put forward by the BMA without proper, due debate of the concerns engendered by such an important issue.
The paucity and poor quality of the record-keeping and follow-up data at GIDS and elsewhere is not a reason to suspect the review’s findings; it is a testament to the problem.
The experimentation of treatment on children for puberty blockers was conducted in an unsound and unsafe manner. There are clear clinical reasons to suspect a number of potential harms following PB treatment. The BMA’s call for a pause to Cass’s pause is a bad call.
I guess the question is where the burden of proof lies.
Personally I think the burden of proof lies on those who want to prescribe a treatment that is now deeply controversial – IE hold off prescribing until new evidence / analyisis emerges.
Others might argue that the burden of proof is with those who advocate stopping the provision of a previously accepted treatment. (And they think the Cass report is insufficient proof.) I can understand, if not agree with, this view.
Edit for clarity
“Personally I think the burden of proof lies on those who want to prescribe a treatment that is now deeply controversial. This view would necessitate holding off prescribing until new evidence / analyisis emerges.”
The BMA is supposed to represent us and that is their only purpose and remit.
I an concerned that they are interfering in an independent review and without the input of their members as they represent us and this implies this is on our behalf.
Having read extensively around this review and the previous Tavistock services I personally do not even thing they should be involved.
Do they pass judgement on specific reviews in cardiology or obstetrics. Not sure.
But certainly ‘urging a pause’ is well beyond their remit.
Doing a good job recently being our union, ie doing their job. The Cass review is for the specialists and/or Royal colleges to review, methodology and interpretation.
IN case it’s not obvious; Paediatrics, gender endocrinologists, psychologists and Gender identity specialists.
One of the private paediatric specialist services is abroad based in Singapore, a Mermaids senior member was on the executive board of that company with a financial interest and I have had parents pushing me as a GP to deal with private referrals to this service when I would then be potentially prescribing treatments in the future that I have no training for.
I’ve also read the book on the Tavistock services by the journalist; Hannah Barnes; ‘Time to think’. Everyone should read it.
Personal accounts by psychologists who treated patients. Everyone should read it. Including the BMA.
I will be writing to them.
I think they are acting well outside their remit and outside their key role in representing us the members.
WE pay for their representation.
I will be writing to them. Considering ending my membership.
Overstepped it. Concentrate on your job, you are our union. That’s it.
First do no Harm.
The Cass report suggests that puberty blockers should only be prescribed as part of rigorous clinical rials of efficacy.
Why would people want to prescribe OUTSIDE of clinical trials?
That would limit the availability of research to support the safe use of such drugs.
It is the same with many treatments that are prescribed ‘off licence’ to children.
Rather than continue to prescribe such items off-licence and deny future children the evidence for or against such treatments, it would be better to enforce that all such prescriptions for anything that does not have a drug licence for children, MUST be supervised by a Paediatrician who includes those children in a research study, to ensure all available eperience is sampled and that enough evidence becomes available for a drug licence.
To try to circumvent inclusion of children in trials or studies for such items is an immoral disservice to all children that might benefit. And smacks of wanting to make a profit from something without wanting to know it’s efficacy and safety.