The finalised Cass Review explores the “current models of care for children and young people questioning their gender identity or experiencing gender dysphoria.”
It is primarily designed for specialist providers. However, as a leading digital provider of mental health services it is vital that we are abreast of the available evidence base and expert opinion across the range of presenting issues, balancing innovation with robust governance structures which Cass highlights as being important.
The Kooth team has reviewed the final report published in April 2024 to ascertain how our services align with the Cass Review’s findings.
The Kooth clinical model
Our clinical model is ‘I-RESPOND’.
I Integrative
R Responsive
E Evidence based
S Safe
P Person focussed
O Outcomes driven
N Non judgemental
D Data led
It sums up everything we set out to do within a clinical framework. All of the components of I-RESPOND align with the interim Cass report findings.
Integrative: We have over 20 years experience in providing a holistic approach where one size doesn’t fit all
The Cass Review is focussed on the provision of care for a specialist cohort requiring highly complex and specialist interventions, against a backdrop of limited evidence and specialist providers.
It also acknowledges the need for a holistic approach, taking into account a whole host of needs. Kooth’s speciality is in providing holistic support (including via individual counselling as well as self-guided activities and peer support), to individuals with a range of presenting issues, using a combination of evidence based practice and practice based evidence developed over more than 20 years.
We do not favour one therapeutic model over another but rather use some core principles to define our approach as outlined in this model.
Responsive: We provide timely, barrier free access to support, regardless of presentation
Cass warns of ‘diagnostic overshadowing’ whereby young people with complex or a range of needs are not having those needs met by the wider (non specialist) health care system because the gender related presentation ‘trumps’ all else – an issue that is compounded by long waiting lists for specialist services, resulting in significant delays to any form of support.
Cass argues for timely access to care, not just from specialists but from every healthcare practitioner they come into contact with. Kooth’s barrier free access to support through self referral, out of hours service and removal of the usual criteria based thresholds enables this for all of our service users.
Evidence based: We use the available evidence and refer to specialists when needed
Cass concludes that there are major gaps in the research base underpinning the clinical management of children and young people with gender incongruence and gender dysphoria and recommends that services must be run as safely and effectively as possible, within the constraints of current knowledge.
This describes Kooth’s approach. We are not a diagnostic service, however we do work with individuals across a wide spectrum from both a diagnostic and acuity perspective.
All interventions take into account the available evidence base for each presenting condition and we always refer or signpost to specialist services where required.
Safe: Our safety processes underpin absolutely everything we do
Ensuring the safety of our service users is central to all we do at Kooth and we have robust processes for risk management and escalation in line with regulatory and local frameworks.
This is supported by thorough training, clinical audit and supervision. Our platform is fully moderated, to ensure that content published in relation to any issue is not harmful and any distressing communications are responded to in a timely manner. Individuals are not identifiable to each other and cannot make contact outside of the platform.
As well as being pre-moderated before acceptance for publication on our site, content is assessed according to guidance for the lowest age group able to access it and this is based on guidance from a number of resources relevant to the topic. For issues in relation to transgender, the guidance from Cass is key, alongside DoE guidance.
Person focussed: We focus on individual wants and needs, not diagnosis
Cass highlights that young people experiencing gender dysphoria are not a homogenous group and have differing views on a number of factors, including how they wish to be described and the constructs used to help define gender dysphoria.
Cass also highlights that the single most important factor of the review is that at the centre of the debate are young people in distress and that they should have the same access to psychological support as any other young people in distress.
Kooth treats individuals as individuals, looking beyond diagnosis to focus on the personalised wants and needs of all, as assessed by our pioneering session wants and needs measure (see SWAN-OM below) which was developed for our service users and in conjunction with our service users.
Outcomes driven: We have a pioneering research programme to develop fit for purpose outcome measures
Cass refers to the challenges of identifying and tracking what good looks like when it comes to outcomes in this domain due to a range of factors, including lack of agreement regarding the epidemiology, assessment and treatment of this group as part of a wider research programme.
Kooth has a dedicated research function and has always been committed to contributing to the wider evidence base when it comes to improving outcomes.
Our Session Wants and Needs Outcome Measure (SWAN-OM) was designed to measure the effectiveness of single session interventions, which is the mode number of treatment sessions across most services and yet to date, there has been no fit for purpose measure.
Having received initial validation for the SWAN-OM measure by the Anna Freud Centre, we are excited to share this measure with the wider NHS and beyond and believe that this can contribute to learning what good looks like for a whole range of cohorts - particularly those for whom the treatment evidence base is lacking.
Non-judgemental: We create a safe environment where there is no fear of judgement
Cass acknowledges that there are quite polarised views among service users, parents, clinical staff as well as the wider public about how gender incongruence and gender-related distress in children and young people should be interpreted, and this has a bearing on expectations about clinical management.
Cass highlights this is exacerbated when there is no space to have open, non-judgemental discussions about these differing perspectives.
At Kooth, we welcome all individuals regardless of background and our aim is to encourage those individuals to achieve their wants and needs through respectful and safe interactions, guided by the available evidence.
This includes (moderated) discussions within our forums and discussion groups where a range of views may be shared to support self and other learning, without fear of judgement.
Data led: We use data as much as possible to guide best practice and are keen to share this
Cass highlights the importance of the systematic and consistent collection of data with any service improvement, including through tracking service user pathways. Kooth has thousands of data points for thousands of young people, several of whom present with gender related issues.
In addition to using this data internally to guide practice as well as service development and training needs, we continue to have a transparent approach to sharing our data more widely, to help to fill knowledge gaps across a range of areas and ultimately contribute to the development of a more robust evidence base when it comes to mental health and wellbeing for our children and young people.