A content note: these proposals may make for heavy reading for those accessing, or hoping to access, children and young people’s gender services in England. Take care while reading.
NHS England has launched a consultation running from 20 October to 4 December on how the future gender services should run in the new clinics opening in Spring 2023.
Mermaids has significant concerns about these proposals, which will likely add more barriers to accessing care. They suggest that young people should be prevented from exploring social transition (e.g changing name or pronouns) unless diagnosed with “clinically significant distress”, and that young people seeking gender-affirming treatment outside of the NHS (e.g. private clinics) could be seen as at risk or a safeguarding concern.
We will be publishing advice on how to respond to the consultation shortly, but wanted to explain some of what’s going on first. There are still many unanswered questions, but we have tried to break down what we know so far.
What is the consultation about?
Last week, NHS England released proposed guidelines for trans and gender diverse young people who require gender health services. Known as a “service specification”, it is essentially a guidance manual on how gender services are expected to run.
The guidelines are “interim” which means that they will only be used for a limited time until a new, more permanent “service specification” is formed after The Cass Review concludes.
NHS England is running a consultation on these interim guidelines meaning the public and relevant organisations, like Mermaids, can provide feedback about what they like, and what they think needs to change.
Earlier this year, NHS England announced that NHS Tavistock and Portman’s Gender Identity Development Service (GIDS), England’s sole provider of gender health services for children and young people, is being replaced in Spring 2023.
This followed recommendations made in February by Dr Hilary Cass, who has been given the job by the NHS of reviewing the current healthcare options available to gender-diverse youth.
In her interim (i.e. not final) report, Dr Cass identified that young people were experiencing extremely long waiting times to access gender health services and that the existing model was unsustainable.
Dr Cass then wrote to NHS England in July to recommend GIDS be replaced by multiple new regional hubs, which started this process.
What changes are proposed?
- Two new clinics will be established – one in London and one in the North West of England, as part of a pilot. Existing patients or those on the waiting list for GIDS will be transferred to these services.
- The introduction of yet another stage before even joining the waiting list. This will be between the new service and the professional who referred the young person (e.g. a GP) to determine whether they meet the criteria for a referral to the service. Even those who meet the criteria might not be added to the waiting list. The document says local professionals will be able to provide alternative support.
- Currently, the long waiting times mean many families seek private providers to access the healthcare required by a young person. If they do, the new service will not take on any clinical responsibility for monitoring these patients (this is currently the case), and will also encourage the patient’s GP to “initiate local safeguarding protocols” (e.g. referral to the local authority’s social care department). Noting that supporting your child’s gender exploration with private clinical support is not a safeguarding issue, the claim here is tenuous at best.
- When a young person is taken on by the service, clinicians are now advised to only consider supporting “social transition” – i.e. changing name, pronouns, clothing – if they experience what is described as “clinically significant distress“.
- The guidelines continue to allow for young people to be prescribed “puberty blockers” – which pause puberty giving time for a young person to explore their options. However, they will be required to take part in research as they grow up to become adults.
What do we think of it?
While an additional clinic should add capacity to an overstretched service, we are concerned that proposals will increase the barriers to care, and treats being trans as an illness, rather than an expression of someone’s authentic self which might require additional support. There are also many unanswered questions on how this would work in practice.
The introduction of an assessment prior to joining the waiting list will add further delays to a service already unable to meet the level of need. Among those young people able to access healthcare through a private provider, the guidelines will deter families from speaking with their GPs and accessing any NHS service, denying them the care they need (e.g. blood tests and general health).
For many young people, social transition is a vital way to preserve their mental wellbeing and be their authentic selves – it shouldn’t require medical approval.
International best practice states that “recognition that a child’s gender may be fluid and develop over time… is not sufficient justification to negate or deter social transition” (World Professional Association for Transgender Health (WPATH) Standards of Care (SOC8, 2022) Available at: Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 (tandfonline.com), p. S75). This section clearly supports anti-trans views and could create fear and misinformation in various areas of life.
There are other more specific areas of concern which we will expand on in our consultation response guidance.
Despite our concerns, it is important to state these proposals are not finalised, and must take consultation responses into account.
We would expect these interim guidelines to be published in the new year, and GIDS at the Tavistock and Portman Clinic will continue to operate as usual in the meantime.
There will be further opportunities to make our concerns known ahead of the publication of the final, more permanent guidelines following the conclusion of the Cass Review.
We would encourage those concerned about these changes to respond to the consultation, which we will be publishing advice on soon.
No matter the outcome of this service review, Mermaids will continue to support trans and gender diverse young people and their families to access the healthcare and support they need to live the happy and fulfilling lives that they deserve.