Social transition in children could create urgency for puberty blockers – report

The Cass Review has called for a ‘more cautious approach’ to children making these changes before puberty.

The Cass Review has called for a more ‘cautious’ approach to children who are confused about their gender (Danny Lawson/PA) (PA Wire)

Children changing their pronouns, names and clothes from a young age could lead to a greater sense of urgency for medical interventions such as puberty blockers, according to a major review.

It has called for a “more cautious approach” to children who are confused about their gender making these changes – known as social transition – before puberty.

The probe also heard from some parents who said they felt “forced” to affirm their child’s gender identity as they were scared of being accused of transphobia.

Others said transitioning had boosted their child’s social life and made them more popular.

It seems to have been socially beneficial to her to present as trans – as a high functioning autistic person – it has helped her with her social life

The findings form part of the final report from Dr Hilary Cass in her independent review of gender identity services for children and young people.

Also known as the Cass Review, it was commissioned by NHS England and NHS Improvement in 2020 following a rise in the number of youngsters seeking help for issues with their gender.

It cited a report by the Multi-Professional Review Group (MPRG), which was set up by NHS England to review cases referred to the endocrinology clinic for puberty blockers.

It said the group had raised concerns about children who had transitioned early and are now “living in stealth”, with their peers and teachers unaware of their birth-registered sex.

These youngsters have a fear of “being found out”, and either rejected for with holding this information or becoming a victim of transphobia, which the review suggested could be driving a sense of urgency to access puberty blockers.

Last month, NHS England confirmed children will no longer be prescribed puberty blockers at gender identity clinics, saying there is not enough evidence to support their “safety or clinical effectiveness”.

In most cases, children and parents were asking to progress on to puberty blockers from the very first appointment

The Cass Review

Going forward, they will only be available to children as part of clinical research trials.

The MPRG report added that many children and young people had either started transitioning or fully transitioned in the time between their referral to the gender identity development service (Gids) and their first appointment.

It said that “in most cases, children and parents were asking to progress on to puberty blockers from the very first appointment”.

The Gids at the Tavistock and Portman NHS Foundation Trust closed almost two weeks ago, with new regional hubs launched in London and the north of England in a bid to move away from a single-service model.

Academics from the University of York spoke to 14 young people between the ages of 12 to 18 seeking support from the specialist NHS gender services in England.

Facing long waiting times, which impacted their mental health, many opted to socially transition in the meantime.

These young adults acknowledged that their original response was to 'fix' the problem. This became less important to them as they grew older

The Cass Review

While some patients were positive about talking to clinicians at Gids who understood them, other expressed frustration at the amount of talking therapy required.

Researchers said some youngsters “believed talking slowed down or prevented access to medical pathways”.

The team also interviewed 18 patients between the ages of 19 and 30, with some saying their “initial gender questioning created a sense of urgency, much of which focused on accessing medical pathways”.

“These young adults acknowledged that their original response was to ‘fix’ the problem,” researchers added. “This became less important to them as they grew older.”

The Cass Review also heard from parents whose children had socially transitioned without their involvement, with teenagers “coming out” to their peers while being worried about how their parents might react.

Some parents said this stance left them feeling “forced” to affirm the gender their child wanted to identify as or risk being accused of being transphobic or unsupportive.

Others told the review they were of the opinion that being trans had helped their child’s social life.

One said their “geeky and awkward” child had been bullied prior to transitioning but later “became a celebrity”.

Another said: “It seems to have been socially beneficial to her to present as trans – as a high functioning autistic person – it has helped her with her social life.”

The Cass Review highlighted that social transition “may not be thought of as an intervention or treatment, because it is not something that happens in a healthcare setting”.

However, it said it is “important” to view the measures as an active intervention as they “may have significant effects on the child or young person in terms of their psychological functioning and longer-term outcomes”.

For those going down a social transition pathway, maintaining flexibility and keeping options open by helping the child to understand their body as well as their feelings is likely to be advantageous

The Cass Review

The report recommended that families of children who are discussing social transition before puberty should be seen by doctors as early as possible.

It said that while there is “no clear evidence” that social transition can positively or negatively impact mental health in childhood, it could “change the trajectory” of a child’s gender identity development.

“For this reason, a more cautious approach needs to be taken for children than for adolescents,” it added.

“For those going down a social transition pathway, maintaining flexibility and keeping options open by helping the child to understand their body as well as their feelings is likely to be advantageous.”

It recommended that partial, rather than full, transition “may be a way of ensuring flexibility” for children, particularly among those who transition at an early age, which it said “may add to the stress of impending puberty and the sense of urgency to enter a medical pathway”.

The review pointed out that “exploration is a normal process” for teenagers and said “rigid binary gender stereotypes can be unhelpful”.

For teenagers considering full social transition, the review said long waiting lists “make it unlikely that a formal clinical assessment will be available in a timely manner” but called on parents, carers, teachers and clinical staff to provide support with decision-making.

The report stressed that outcomes for both children and teenagers “are best if they are in a supportive relationship with their family”.

It urged parents to be actively involved in decision making around social transition.