Cass Review

With your permission, Madam Deputy Speaker, I would like to make a statement on the Cass review of gender identity services for children and young people. May I say how pleased I am that we are joined by parents of children who have been affected by some of the issues raised in this review? I hope all of us will bear the sensitivities of this debate in mind as we discuss it this afternoon.

This review strikes hard and sure at an area of public policy where fashionable cultural values have overtaken evidence, safety and biological reality. This must now stop. As recently as 2009, the NHS’s sole gender identity development service at the Tavistock and Portman NHS Foundation Trust received fewer than 60 referrals for children and young people, and just 15 for adolescent girls. Since then, demand has surged. By 2016, over 1,700 children and young people a year were referred—a 34-fold increase. More than half were teenage girls. In 2022, more than 5,000 children and young people were referred to gender identity clinics, and almost three quarters were female.

This exponential increase in demand is not a coincidence; it has been driven by a number of factors which I will come to later, but at its heart it was driven by a myth. This myth was that for children and young people grappling with adolescence who were questioning their identity, their sexuality or their path in life, the answer to their questions was inevitably to change gender to solve their feelings of unease, discomfort or distress.

That near-uniform prescription was imposed on children and young people with complex needs without full and thoughtful consideration of their wider needs, including, as is set out in the report, conditions such as neurodiversity, experiences such as childhood trauma or mental health conditions, or indeed discovering who it is that they may one day fall in love with. Indeed, the response from some of the people who should have protected them—some of the clinicians in charge of their care at the Tavistock clinic—was almost always to put them on an irreversible path: blocking puberty, then prescribing cross-sex hormones, and on to surgery as an adult. In other words, such professionals were not asking the right questions of themselves or of their patients.

That is why in 2020, with the support of my predecessors, my right hon. Friends the Members for West Suffolk (Matt Hancock) and for Bromsgrove (Sir Sajid Javid), NHS England commissioned Dr Hilary Cass to examine the state of services for children questioning their gender. I would like to start by thanking Dr Cass and her team for undertaking a considered, comprehensive and courageous review into an extremely contentious area of healthcare. Since NHS England commissioned the review in 2020, they have meticulously unpicked what went wrong, what the evidence really shows and how to design a fundamentally different service that better serves the needs of children.

I must also thank those who raised the alarm and contributed to the review over the last four years: the clinicians who spoke up against their peers to blow the whistle about what was happening at the Tavistock clinic, even though it risked their careers; the journalists, academics and activists who listened to their stories and investigated further, even when they were derided as bigots and transphobes; the parents who were just trying their best to support their children, but were so badly let down by a service that vilified them for questioning whether the interventions offered were right for their children; and, of course, the young people themselves who have shared their experiences, including those who have gone through the pain of de-transitioning only to find out that the so-called “reversible” treatments they were offered are not in fact reversible.

The Cass review makes for sober reading. It is extremely thorough, so I will not attempt to cover all its recommendations today, but I genuinely encourage all Members to read the report in full. It should concern every single Member of this House that part of our public space—the NHS—was overtaken by a culture of secrecy and ideology that was allowed to trump evidence and safety. We say enough is enough; our young people deserve better, and we must do whatever it takes to protect them.

Since the publication of Dr Cass’s interim report in 2022, a series of important changes have been made, and I put on record my thanks to NHS England’s chief executive, Amanda Pritchard, and all those at NHS England who have worked hard with Dr Cass to implement them. On 31 March, the Tavistock clinic finally closed, having stopped seeing new patients a year earlier. Two new regional hubs have been opened, in partnership with the country’s most prestigious children’s hospitals, to ensure that children are supported by specialist, multidisciplinary teams. Indeed, another hub will follow in Bristol later this year.

In the past few weeks, NHS England made the landmark decision to end the routine prescription to children of puberty blockers for gender dysphoria. On the day of publication of Dr Cass’s final report, it announced that it is stopping children under 18 from being seen by adult gender services with immediate effect, and an urgent review on clinical policy for cross-sex hormones will now follow without delay. I also welcome NHS England’s plans to bring forward its full review of adult services, including Dr Cass’s recommendation for a follow-through service for young people up to the age of 25.

I also share Dr Cass’s concerns that clinicians who subscribe to gender ideology will try to use private providers to get around the rules. Let me give a very clear warning: prescribing is a highly regulated activity, and the Care Quality Commission has not licensed any gender clinic to prescribe hormone blockers or cross-sex hormones to people under the age of 16. Any clinic that does may be committing extremely serious regulatory offences for which its licence can be revoked and its clinicians can be struck off. My officials have been in contact with the CQC following the final report to ask that it looks again at the age thresholds in its licensing conditions.

The CQC has also reassured us that it will incorporate Dr Cass’s recommendations into their safe care and treatment standards for all care providers. That means that all new providers will be asked if their practices respect the Cass review, and all existing providers have to meet the same rigorous standards when they are reviewed by the CQC. My officials met the General Medical Council over the weekend, and will do so again in the coming days, to understand how it will ensure that every clinician on its register follows its code of practice and implements the wider findings of the Cass review.

It is morally and medically reprehensible that some online providers not registered in the UK have stated their intention to continue to issue prescriptions to children in this country. I am looking closely at what can be done to curtail any loopholes in prescribing practices, including legislative options. Nothing is off the table, and I will update the House in due course as we progress that work at pace.

Dr Cass also found that there was a lack of robust data on what happened to the 9,000 children who were treated by gender identity services between 2009 and 2020. Many went on to continue their treatment at adult clinics, and the University of York had been due to research the long-term consequences of treatment they received as children, so that we can properly support them through their journey into adulthood. It was expected to provide important insights into the clinic’s work, including how many patients de-transitioned and how many were also diagnosed with a mental health condition or an autism spectrum disorder.

This Government took the unprecedented step of changing the law to make it possible for adult gender clinics to share medical data with the university. All bar one of the adult gender clinics refused to co-operate with this vital research. To quote Dr Cass, that is “unacceptable”, but I would go even further: I think it is deplorable and a dereliction of their professional duty. I am pleased to update the House that following the publication of Dr Cass’s report, I have been informed that all seven clinical leads for the adult gender services now intend to fully participate in this important work.

Dr Cass also concludes that a cultural shift alone “does not adequately explain” the huge growth in young women being referred to gender services. She paints an alarming picture of digitally engaged young women who are frequently exposed to pornography involving violent, coercive, degrading and pain-inducing acts. Is it any wonder than more and more of them are looking for ways to opt out of becoming women? That is deeply troubling and, as Dr Cass makes clear, we have a duty to support those young women with considered, evidence-based care.

Our children deserve healthcare that is compassionate, caring and careful. Their safety and wellbeing must come above any other concern, and anyone who threatens it must be held to account. I will work with NHS England to root out the ideology that has caused so much unnecessary harm, to support those who have already received life-altering treatment, to give the next generation access to holistic care, and to protect our children’s futures. Anything less would be neglecting our duty to the next generation. That will not happen under this Government, and it will not happen under my watch.

I call the shadow Secretary of State.

I thank the Secretary of State for advance sight of her statement and, even more importantly, Dr Hilary Cass and her team for the thoughtful and thorough way in which they have undertaken their work. Dr Cass has navigated the complexities and sensitivities of the subject with academic rigour, providing an evidence-led framework for children to receive the best possible healthcare. I also pay tribute to journalists such as Hannah Barnes and the whistleblowers who together helped to shine a light on what was going on at the Tavistock clinic.

At the heart of the complexity around this issue are two things that are true simultaneously. There are trans adults in this country who have followed a medical pathway and who say that, for all the pain and difficulty that involved, it was not just life-affirming; it was lifesaving. There are also people in this country who followed a medical pathway but who say it was a disaster that ruined their lives irreversibly, and they ask how anyone could have let that happen. For the sake of all those children, young people and now adults—but particularly those being referred into gender identity services today—we have a duty to get this right.

What has emerged in the Cass review is a scandal. It is a scandal that children and young people are waiting far too long—often years—for care while their wellbeing deteriorates and their childhood slips away. It is scandalous that medical interventions have been made on the basis of shaky evidence. It is scandalous that, despite all that, some NHS providers refused to co-operate with Dr Cass’s review. Perhaps the worst scandal of all is that the toxicity of this discussion means that people have felt silenced, and it required investigative journalism to prompt the review to take place. This particularly vulnerable group of children and young people are at the wrong end of all the statistics for mental ill health, suicide and self-harm. There is no doubt that they have been very badly let down, so we owe it to them to approach this discussion with the same care and sensitivity with which Dr Cass undertook her review.

I welcome all those who have changed their minds about this critical issue. In order to move forward and get on with the vital work that Dr Cass recommends, we need more people to face up to the truth, no matter how uncomfortable that makes them feel. I hope the hon. Gentleman has the humility to understand that the ideology that he and his colleagues espoused was part of the problem. He talked about the culture and the toxicity of the debate. Does he understand the hurt that he caused to people when he told them to “just get over it”? Does he know that when he and his friends on the left spent the last decade crying, “Culture wars,” when legitimate concerns were raised created an atmosphere of intimidation, with the impact on the workforce that he rightly described? People were scared or worried to go into it.

Does the hon. Gentleman now have the good grace to apologise to those who have been maligned in public life—including his own female colleagues—and for the chilling effect that this has had on clinicians, journalists and campaigners who were trying to raise the alarm? I say that because I want to believe the hon. Gentleman when he says that he has turned a corner on this issue. We have to start with a new page, for the sake not just of the children and young people we are looking after but of their families, many of whom will be watching this, living with the consequences of the ideology and secrecy, wondering how on earth the hon. Gentleman talks about general elections when, every single minute and day, their children have to live with treatment that can never be reversed.

The report is very welcome, but it has been a long time coming. One issue I would like to put to my right hon. Friend is the whole failure of governance that it shows. In particular, NHS England’s specialist commissioning requires challenge. As she explained, what was initially commissioned as a treatment course for a small minority of people has been allowed to expand unchecked and without any consideration of the ethics of what was being done to children. What will she do to ensure that does not happen again? Secondly, the Tavistock clearly enjoyed the popularity brought by being at the front end of what was seen as a set of cutting-edge treatments. Frankly, the governors allowed that to get in the way of what they should have been doing: ensuring patient safety. What does she propose to do about that as well?

I thank my hon. Friend, who in her parliamentary career has done so much to shine a light on this sort of behaviour. She has espoused worries, both publicly and privately, about the children and young people at the heart of this matter. Looking to the future, the Tavistock clinic has shut. As I said, it stopped admitting patients a year ago. The new services that are already in place—the two new hubs, with plans to expand further across the country—are about ensuring a multidisciplinary approach to young people, so that, with exactly the experiences Dr Cass sets outs so starkly in her report, children are treated as human beings and patients, not as siloed conditions. One of the main problems that emerged with the Tavistock behaviour and the way it took place is that gender questioning was siloed in a way that no other health or mental health condition was. We want to move back to a place where clinicians are no longer scared of looking after children and young people with these issues, and that they see it as part of their general practice and general work. That is how we are best going to address the very complex needs of many of these children and young people.

I call the SNP spokesperson.

I am grateful for advance sight of the statement.

Nobody’s identity should be up for debate, and nor should it be used as a political football. Dr Cass said in her report:

“Polarisation and stifling of debate do nothing to help the young people caught in the middle of a stormy social discourse, and in the long run will also hamper the research that is essential to finding the best way of supporting them to thrive.”

That polarisation is the last thing needed by young people in accessing care, their families and the NHS staff working hard to care for them. Does the Secretary of State agree that we must all remain respectful at all times when discussing these important issues, and that decisions on this and any other type of treatment should rightly be made by clinicians, not politicians?

Dr Cass explicitly makes the point that her report is not about questioning trans identities or rolling back access to healthcare for young trans people. Indeed, supporting and improving the gender identity healthcare system for all, including children and young people, is what we should be focused on. So can the Secretary of State confirm today whether any additional funding will be made available to ensure that young trans people can access the quality healthcare they need and deserve?

Finally, on conversion practices, the Government Equalities Office said last month in an answer to a written question:

“The Government expects to deliver a draft Bill that takes account of the independent Cass review”.

Can the Secretary of State provide an update on what conversations she has had with Cabinet colleagues on how the Cass review will influence the UK Government’s legislative proposals on banning conversion practices, and when can we expect them to be published?

I encourage both the Scottish National party in Scotland and Labour in Wales—health is devolved in those countries, of course—to respond as quickly as possible to the findings of the review. The hon. Lady asks whether it is Barnett-ised. For these purposes, our work to ensure that the clinics meet the needs of our population in England is not additional money. We are re-prioritising within NHS budgets to ensure that the services are spread across the country. I encourage the Scottish nationalists to prioritise the needs of their children and young people in the same way.

I would also gently make the point that, when it comes to the atmosphere of this debate, I do not believe it has been helped by the SNP’s highly controversial Hate Crime and Public Order (Scotland) Act 2021. I note, for example, the behaviour and engagement on Twitter of very high-profile people in Scotland, and the impact that it has had when people have dared to name activists in this arena. I would also ask the Scottish Labour party to explain why it helped the SNP to pass that Act, because to me this seems to be all about the atmosphere.

I call the Chair of the Women and Equalities Committee.

Dr Cass’s observations about violent and degrading pornography are chilling, and we know of the impact that is having not just on young girls but on all our young people. Her recommendations also include significant and specific references to expanded services and follow-through services for 17 to 25-year-olds. What concerns has my right hon. Friend about the capacity for that, and about the possible impact on other areas of healthcare?

We know that the transition from children’s services to adult services can be problematic in the case of a wide range of services, not least for those suffering from body dysmorphia or eating disorders. Might there be any crossover, with young people having access to some sort of interim service before the age of 25, and will more funds be committed so that we do not continue to see what all of us will face in our constituencies: the horror of young people being unable to access child and adolescent mental health services before they turn 18 and become reliant on adult mental health care?

My right hon. Friend is right to identify the cohort of young people between the ages of 17 and 25 as being of particular concern. Now that we have a clear pathway in relation to the treatment of children and young people under the age of 17, I have asked NHSE to focus primarily on that next cohort. Speaking to parents gives one a very real sense of their concerns about what they describe as the cliff edge between children and young people’s services and adult services for this very vulnerable group of young people. I do not want that to continue, and over the coming months we will see NHSE develop work to help that cohort.

My right hon. Friend has an understanding not just of how transformational the report and its evidence are, but of the challenges that this means for our health service in England and how we choose to respond. As for funding, NHSE has committed more than £17 million to the two new hubs in the current financial year, and I hope and expect that our devolved Administrations will commit similar sums to looking after children and young people in their areas.

The Secretary of State has spoken of the need for multi-site centres, and has pointed out that two hubs have already been established. Will she tell us a little more about her plans to expand this to make it multi-site, and when that is likely to happen?

As I have said, we hope to expand it to Bristol later in the year, and there will be a further three or four sites across England. However—this is a really important part of the report—this is not just about specialist services but about giving clinicians the necessary confidence to look after children and young people who may well be presenting at their clinics or surgeries with this condition as one of a number of conditions. We want to give them back that confidence, and the comfort of knowing that they need not just go down the narrow pathway of specialist services. Of course that will be appropriate for many, but we want to treat the whole child rather than treating just this particular condition, as has happened in the past.

I must first declare my interest as a practising NHS consultant paediatrician whose practice sometimes involves caring for children with the condition we have been describing.

The Cass Review makes for sobering reading. This is an example of ideology being allowed to trump evidence and safeguarding. Let me give the Secretary of State a specific example. Individuals have thwarted the attempts of those working on the report to conduct research that would give them a better understanding of the outcomes for some children. I am pleased to hear that those people are now co-operating, but we should note the contents of a letter from John Stewart, the national director of specialised commissioning, which is appended to the report. He says that although NHS England wrote to the chief executives and medical directors of all NHS trusts, the research data was not released. One of the duties of doctors that are specified by the General Medical Council is to

“Engage with colleagues to maintain and improve the safety and quality of…care.”

May I ask the Secretary of State who exactly blocked that data, what investigations will be carried out to find out which individuals were responsible, and how they will individually be held accountable for their actions? How was it possible for them to do this in the first place, and what is she doing to ensure that data cannot be blocked in the same way in the future?