Cass Review is a breath of fresh air - we now need one for gender-distressed adults
By Dr Kathryn Webb
As a clinical psychologist, the release of the Cass Review has been long-awaited. Although the review focused on the specialist Children’s GIDS service, it also highlighted the crisis in wider mental health services nationally (and even globally) on how to support these young people. Even at the world-leading University of Oxford, psychologists have felt uncertainty about what they should be delivering to patients and teaching to students.
For too long, the current approach to gender dysphoria care has left many of us feeling that fundamental principles of our profession were being neglected. At the heart of our practice should lie a commitment to understanding and supporting individuals holistically, through evidence-based practice.
Amidst politicisation of work in this area, escalating referrals, and a struggling healthcare system, some believe these principles have been abandoned. With little resistance from bodies such as the British Psychological Society, the existing approach meant clinicians had limited ability to offer much more than a medical-focused pathway, with “affirming” a child’s self-expressed gender identity as a panacea for often highly complex case presentations.
The role of psychologists was side-lined and constrained - we were pressured to overlook the broader psychological landscape in which gender identity exploration and distress occur. This is “diagnostic overshadowing” in its worst form.
Emphasis on a drive for evidence-based practice
As Cass highlights, we ended up here largely due to a lack of rigorous guidance worldwide – only Sweden and Finland were assessed to meet international guideline development standards. Underscoring this is a shocking absence of quality research to base guidance upon. This is unsurprising to me, having personally experienced the resistance often faced when conducting research in this sensitive area.
In the absence of science, policies have instead looked to activism. Consequently, professional bodies have repeatedly released guidance which is, at best vague, and at worst unevidenced and politically-driven. Indeed, many clinicians have been ignored and (like James Esses) even punished by their governing organisations for raising concerns – the same concerns organisations now acknowledge in the wake of the review.
As a result, psychologists have felt adrift and afraid, unsure if we were truly serving the best interests of our patients.
Therefore, the Cass Review’s emphasis on caution, a more holistic care model, and a drive for evidence-based practice is a breath of fresh air. It encourages us to recognise the importance of considering factors such as mental health, family dynamics, and past trauma.
The review reaffirms our commitment to working with the whole person — not just their gender identity. Finally, by calling for better research and changes to be focused on evidence, it redirects decision-making back to this, a core medical tenant.
Politicisation, poor evidence and limited options
Many are asking how a national pathway for highly vulnerable children could have developed so many fundamental issues. They are right - not to seek blame, but so that we can understand how we got here, and avoid repeating past catastrophes.
The review focuses only on children and their support, yet many gender-distressed adults are arguably equally vulnerable. Sadly, adult care is likely to be affected by many of the same highlighted issues - politicisation, poor evidence and limited options. It is clear that our learning should be applied here too, with a call for adult service investigation.
As we move forward, it is essential that we embrace the lessons of the Cass Review. For psychologists, it is a call to step up and recommit ourselves to the principles of our profession. Our role will be vital in change.
By integrating recommendations across NHS practice, we can ensure that we are providing the best possible care for gender-questioning individuals of all ages.
Dr Kathryn Webb is a clinical psychologist and a visiting academic at the University of Oxford
