Mai 2024
trad. fr.
1. General Comments on the Review and its quality
ACP-UK commends and strongly supports the Review and its recommendations. We congratulate Dr Cass and her team on a truly impressive and comprehensive body of work, conducted and completed in the most hostile, fractious and challenging of circumstances.
The Review, and the nine accompanying systematic reviews, is the culmination of a four-year process. It has employed the highest clinical and research standards available at this time. We particularly commend the extensive consultation with a range of stakeholders and, most importantly, the young people who use services and their families. We also commend the use of an independent group of researchers to evaluate the evidence base dispassionately and with professionalism, applying the same standards of evidence used by NICE and SIGN. We acknowledge the absence of randomised controlled trials in this area but note that nearly 60% of the published quantitative studies were included in the systematic reviews, and that the studies included were rated ‘high’ and ‘moderate’ quality according to the Newcastle Ottawa criteria.
2. Key issues
The key issues of relevance to ACP-UK as the professional body for clinical psychologists include:
That clinical practice at the Tavistock Gender Identity Development Service (predominantly led by clinical psychologists, no doubt with the best of intentions for their patients) did not always employ standard psychological approaches such as psychological formulation and close adherence to the available evidence base. This represented a significant departure from the orthodox modus operandi of the profession.
Despite being psychologist-led, the service employed predominantly medical/endocrinological interventions, often with insufficient consideration of psychological factors
ACP-UK acknowledges and agrees that the clinical approach to gender identity must take account of the developmental stage of the individual, with marked differences between those presenting during childhood, adolescence and adulthood. This includes prioritising patient safety and operating in the best interests of children and their families, whilst also attending to service user opinion and desires.
There has been, and continues to be, an unhelpful discourse which frames and polarises the debate into trans-affirmative vs transphobic.
The Cass Review concludes that much of the quoted evidence in this area is unreliable and cannot be used as a basis for clinical practice, particularly given the significant and irreversible nature of the medical interventions and their potentially deleterious side effects, in a highly vulnerable patient group. Misrepresentation of the evidence does a disservice to this cohort of patients, and to their families.
ACP-UK is deeply disturbed by the deliberate lack of co-operation of adult gender identity services with requests for follow-up data on former GIDS patients. Cass concludes that we need more better-quality evidence upon which to make clinical decisions. ACP-UK therefore welcomes the intervention of the Health Secretary to encourage these services to make their clinical data available.
ACP-UK notes that funding cuts to child mental health services over the past 15 years have resulted in those services being overwhelmed by demand, with the result that young people and their families often wait many months for assessment and treatment, or cannot access services at all.
Clinical psychologists will continue to be at the forefront of gender identity services and ACP-UK considers this entirely appropriate; however, those involved should employ standard evidence-based practice including broad, biopsychosocial assessment and formulation as Cass recommends.
ACP-UK welcomes the Cass Review recommendation for ACP-UK’s involvement to develop a shared skills and competency framework, to develop a training curriculum (points 18.43 to 18.50) and will collaborate with the implementation of the Cass service recommendations.
In supporting the Cass findings and recommendations, ACP-UK also supports the rights and aspirations of trans adults and gender-questioning and trans-identifying children and supports their access to safe and effective evidence-based care.
3. Comments on the empirical findings of the Review
ACP-UK notes the following key empirical findings:
The systematic review found that there is insufficient high-quality evidence to conclude that hormone blockers are effective in suppressing puberty without any adverse consequences. In some cases they compromise bone density, sexual function and fertility, but we do not currently have enough quality evidence to be able to fully assess these risks.
There is not enough good-quality evidence to conclude that hormone blockers improve gender dysphoria, mental health or rates of suicide.
The Review explains that the majority of children and young people who present with gender dysphoria will not go on to pursue gender transition in adulthood. Presently, there is insufficient evidence to enable clinicians to predict who will persist and who will desist. As such, no clinician can predict with certainty whether a medical pathway might benefit or harm any particular child, even after a thorough assessment.
The Review describes a dramatic demographic shift, from relatively small numbers of predominantly birth-registered male gender dysphoric children and adolescent referrals to a marked increase of predominantly birth-registered females.
Many of this cohort of young people also present with significant mental health co-morbidity and neurodivergence.
To date there has been little clinical or academic curiosity about the causes of this change.
We note that the Review questions whether systemic factors such as social media use, early exposure to pornography and internalised and structural homophobia, might be relevant to this change.
Taken together, this reinforces the clinical need for holistic assessment and biopsychosocial formulation for the young person and their family.
We support the Review’s calls for robust scientific investigation into a range of factors that might have contributed to the increase in number and complexity of children and young people seeking referrals to gender clinics. We note that to date there is a remarkable dearth of high-quality longitudinal research in this area and encourage such studies to be conducted.
4. Comments on the recommendations for the new services and the key role of clinical psychology
ACP-UK welcomes the Cass Review’s emphasis on the importance of holistic biopsychosocial formulation and empirical evidence in the clinical approach to gender dysphoria, as with every other clinical presentation.
We would also point to the crucial importance of the therapeutic relationship and note that the building of such relationships requires sufficient time and face to face interaction with compassionate team members.
We recognise that young people and their families referred to the new services will likely present with high levels of distress and need but note that clinicians working in those services should ensure that sufficient time and attention is paid to all relevant psychosocial factors, as they would when working with any other presentation.
ACP-UK agrees that there are important biopsychosocial differences between gender-questioning children, adolescents, and adults and that different considerations need to apply to each group. This has important implications for the nature of service provision, skill mix and clinical approach at each of these developmental phases.
ACP-UK notes the importance of the role of clinical psychology in both CAMHS and the new specialist Gender Dysphoria Hubs. We support the development of specific, evidence-based gender identity training for CAMHS staff, including clinical psychologists.
As many young people will not access mental health services, similar training and staff support should be made available to those supporting these children elsewhere, including social workers, foster carers and teachers.
It is evident that GIDS clinicians were working in challenging circumstances, with limited staffing levels and long waiting lists. The new services are likely to inherit similarly large waiting lists and will continue to work in a politically challenging context. It is vital that sufficient funding and resource are made available to ensure that holistic assessment and treatment can be offered in a sustainable way and that the staff team is well-supported to prevent burnout and compassion fatigue.
In both the proposed hubs and secondary care provision, team culture and functioning and staff support are crucial to quality care. ACP-UK recognises the challenging political context in this area and advocates for sufficient support, and resourcing, to enable staff to continue to utilise the evidence base and employ comprehensive clinical formulation despite the context.
The Review notes that this topic arouses strong feelings. As such, to date there has been little room for nuanced discussions about how best to provide clinical care to the whole population. Clinicians and academics must now be supported to value and discuss both phenomenological experiences and the evidence base, and to raise concerns about patient safety without fear of reprisal.
The Review makes it clear that a cohort of young people who undergo medical transition will detransition. This population is likely to present with considerable levels of need, and we recognise that they are likely to require specialist care and treatment over a prolonged period.
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