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Mermaids’ policy team explains what the recently published guidelines mean for trans youth in England and Wales

NHS England has published guidelines for how the new Hubs replacing GIDS will deliver children and young people’s gender related healthcare, which will be updated based on the Cass Review’s final report.

While responses from Mermaids and supporters mitigated some of the most harmful proposals from the consultation, the final version continues to restrict, pathologise and undermine access to care.

These guidelines do not come into effect until the new Hubs open, and do not apply to current GIDS patients at this point.

Our main concerns are:

  • Waiting times: nobody will be taken off the ever-growing waiting list, now at almost 7,500 people, until the new Hubs are established. We believe this has been the case for many months, which is wholly unacceptable.
  • Access to puberty blockers: is to be restricted to only those with “early-onset gender dysphoria” as part of mandatory research. 
  • Social Transition: despite improvements since the initial draft, the approach to social transition remains overly medicalised and unclear. 
  • Private Providers: the guidelines still take a punitive approach to families using private providers to access gender-affirming care, unless under very specific circumstances. 
  • Neurodivergent young people fear they will face additional barriers when seeking support. 

An Analysis of the Specification

Waiting times

It is wholly unacceptable that the already excessive 3+ year wait for a first appointment has grown even longer in the period of chaos between announcing the closure of GIDS (July 2022) and the opening of new services later this year.

As of April 2023, there are 7,484 children and young people on the waiting list for a first appointment. GIDS has “ceased commencing new appointments” for the waiting list, which is “likely to remain in place until the new providers begin seeing new patients, planned later in 2023” (Equality and Health Impact Assessment p.19). We understand that few, if any, new appointments have been offered over the past six months. 

Access to Puberty Blockers

NHS England has stated that puberty blockers will no longer be “routinely available” and only be prescribed as part of a research protocol. 

The nature of this research will be decided by a newly established Oversight Board, which has, so far, only approved the development of a study into the use of puberty blockers for those described as experiencing “early-onset gender dysphoria”. 

At no point has this term been defined, and a review of existing literature shows it is predominantly used by discredited researchers who have supported the roll back of transgender rights and anti-trans discrimination protections.

We are particularly concerned that “early-onset” is used alongside “rapid-onset gender dysphoria” in other academic literature, an offensive and debunked theory that argues the rise in young people coming out as trans is a “social contagion” rather than a result of growing societal acceptance. 

International professional bodies specialising in gender-related healthcare disagree with the guidelines’ mandatory research enrolment, emphasising the evidence supporting the safe use of reversible puberty blockers. NHS England appears to be basing its approach on outdated and pathologising theories from gender-critical groups who reject the existence of trans childhood. 

Not only is it deeply unethical to force young people into a research trial simply to access treatment but the restrictive criteria will compound inequalities by forcing families to use expensive private providers, and result in avoidable distress for trans youth. 

Social Transition

The guidelines continue to highlight the supposed “risks” of social transition, however our campaigning has meant that NHS England will no longer require a formal diagnosis of gender dysphoria for clinicians to support socially transitioning. In fact, they state that “Social transition is something that should be led by the young person with family input”.

The approach to social transition for adolescents has been described as “informed consent” yet we feel the language in the specification continues to overly medicalise being trans, in stating that social transition should only happen where it is “necessary” for a young person’s social functioning. We think the choice should always lie solely with a young person. 

For children, the guidelines remain out of step with the experiences of the children we work with, who find social transition to be deeply affirming. Changing your name or pronouns should not be a decision that requires approval or observation from medical professionals. Instead, it is the responsibility of our public services to end the “risk”, such as the stigma and discrimination that trans, non-binary and gender-diverse young people often face. 

Use of Private Providers

Many families were worried by the initial specification which threatened to report parents to local safeguarding authorities if their young person was accessing healthcare through a private provider. It is positive that the NHS has listened to these concerns, and removed this. But the guidelines take an overly punitive approach to those accessing private care. 

Our major concern is that if a young person is rejected under the restrictive eligibility criteria for blockers and/or gender-affirming hormones, clinicians are encouraged to suggest that a young person’s GP “considers what safeguarding protocols may be appropriate”.

Families access private care because they are desperate and have been failed by the long waiting times. They should be supported by the NHS rather than being reported to local safeguarding measures. 

Neurodivergence

Many young people we work with highlighted the ableism present in the idea that their neurodivergence diminished, or “explained away” their trans identity. 

While we welcome greater support for young people around their mental health and other aspects of neurodiversity, this should not create additional barriers for them to access gender-related care. 

In particular, the requirement that clinicians explore the relationship between neurodivergence and gender identity remains a concern that could lead to yet more distressing and invalidating conversations, where neurodivergent patients feel their neurodivergence is framed as a “cause” of their gender identity, rather than existing alongside. 

What’s next?

This specification will come into force when the new Hubs open, in autumn 2023 for the Southern Hub and April 2023 for the Northern Hub. NHS England will also be releasing further guidelines for public consultation on puberty blockers, the referral process, and gender-affirming hormones.

Mermaids is working hard to get more clarity and answers from NHS England and advice for experts in the field, and will share further information when we can.

You can support our work to advocate with and for trans young people and their families by signing up to our mailing list and joining a growing movement of people coming together to create a better world for trans young people. 

If you find any of this distressing and would like some support, do call our helpline on 0808 801 0400. Our team are available Monday to Friday, 9am – 9pm.

Your Questions Answered: The new “interim service specification“

What does this specification do, and when does it start?

A service specification defines the standards of care for a service, in this case, the new Hubs replacing GIDS. This specification will only apply to the new services, which open in autumn 2023 (Southern Hub) and April 2024 (Northern Hub). It will apply until a final specification is made, following the Cass Review’s final report (date unknown).

Is NHS England stopping the prescription of puberty blockers?

Not entirely, but they will no longer routinely prescribe puberty blockers. Only those who are part of mandatory research will be eligible, which currently only includes those deemed to have “early-onset gender dysphoria”.

Who is eligible for the research protocol to be prescribed puberty blockers?

To our understanding, the only research proposed would be restricted to those deemed to have “early-onset gender dysphoria”.

What do they mean by “early onset gender dysphoria”?

We also do not know! The diagnostic criteria is unclear, and the term is largely used by anti-gender groups. Whereas the rest of the guidance uses the ICD-11 framework of gender incongruence or the DSM-5 criteria of gender dysphoria, this term is based on neither internationally-set standard.

What about current GIDS patients who access puberty blockers?

NHS England has previously said that the research protocol will not be applied retrospectively, so won’t affect those already prescribed puberty blockers. We have sought reconfirmation of this.

Will I be referred to local safeguarding measures if I need to access private care?

The guidelines no longer recommend that GPs refer families accessing private gender care (“unregulated medication”) to local safeguarding measures. However, they do still “suggest that the GP or local health professional considers what safeguarding protocols may be appropriate” (p.18) if a patient enters the NHS England pathway already on blockers or gender-affirming hormones, and is not accepted by the service to continue their care. There are various reasons why the service won’t accept continuation of care, listed on page 17, including if they’ve accessed gender-affirming hormones before approximately 16 years of age. 

Do I need a diagnosis to socially transition?

No. The guidelines specifically stated that “social transition is something that should be led by the young person with family input”. However, the guidelines do say children and young people and their families will undergo “an in-depth process of discussion and thinking around the decision of social transition” if they “will present in public fully… in all forms and aspects of their daily lives” (p. 12-13).

I am accessing blockers or hormones from a private provider right now. What does this mean for me? 

There is a possible pathway onto the NHS England services for those accessing private care (“unregulated sources and providers”), which is a welcome change. However, the patient must meet certain criteria (p. 17).

For blockers, they must stop using the medication for a brief period of time to assess a baseline, and be assessed by the service to meet the research requirement.

For gender-affirming hormones, they must have documented evidence of assessment, evidence of multi-disciplinary team support, not start before puberty, have used puberty blockers for 12 months prior, not start before 16 years of age, and have evidence that fertility was discussed. 

What does this mean for neurodiverse people?

The new service will include people with expertise in the direct assessment of autism, ADHD and other forms of neurodiversity. While this could provide more holistic care and support, neurodivergent trans young people we work with worry that the assessment would focus on “fixing their neurodiversity” before supporting their gender incongruence/dysphoria.

Your Questions Answered: GIDS’ closure and new Hubs

In May, NHS England gave updates on the timeline for the Hubs replacing GIDS, which we have explained in another blog. 

Has GIDS at Tavistock already closed?

NHS England announced in May 2023 that GIDS would remain open until at least April 2024, focusing on their open caseload (around 1,000 patients). They are not offering new appointments, although this could change. 

When do the new Hubs start?

The Southern Hub (London-based) is due to open in autumn 2023, and the Northern Hub (Manchester/Liverpool) in April 2024. This was delayed from spring 2023.

Can people still be referred to a service right now?

Yes, people can still be referred to join the waiting list, which is now managed by NHS Arden and GEM. You can contact them at [email protected]. 

What about people still on the current waiting list?

The waiting list is now held with NHS Arden and GEM. Anyone referred to GIDS should have been transferred to them, and will be receiving a letter from NHS England shortly.

Is anyone being taken off the waiting list right now?

No. NHS England confirmed that “GIDS has ceased commencing new assessments” and this is “likely to remain in place until the new providers begin seeing new patients, planned later 2023”.

What about current patients?

GIDS will continue to support their current caseload. When the new services open, we understand that patients will be transferred to the appropriate service.

“It sounds like they are trying to stop trans youth existing”

This month, we published a blog summarising some of the proposed changes to the NHS healthcare services for young trans and gender-diverse people in England. 

The new guidelines were met with anger and frustration by the young people and families we support, with those on our helplines and forums expressing deep concern about the implications to their future wellbeing. 

In response, we held two online engagement sessions, one for trans and gender-diverse young people, and one for parents to listen to their views. 

What struck us most was the message that, in their current form, the proposals categorically fail our communities. Participants strongly felt that NHS England appears committed to denying trans young people the right to be their authentic selves. 

“Literally everyone transforms themselves socially in some way or another”: The right to socially transition

Under the new guidelines, clinicians are now advised to only consider supporting “social transition” – i.e. changing name, pronouns, clothing –  if a young person experiences what is described as “clinically significant distress“.

There was shock amongst young people at this inclusion within the guidelines, who felt this is  reflective of efforts to “medicalise” trans people. In other words, it opens up the possibility that a person will require permission from a doctor to dress how they please, and use their chosen name and pronouns.  

As one young person remarked, social transition is “a thing that people should be allowed to do freely because people, even children, have bodily autonomy.”

Both parents and young people recognised the enormous benefits that social transition can bring to a child’s mental well-being, so far as to be life-saving for some.

There was bewilderment that someone could only access support if they reached the point of showing “significant” distress. “Why would they want young people to get to that point?” one young participant observed. 

Rather than uplift and support trans youth, our participants felt the proposed changes deny them the right to express themselves as they choose – something one parent suggested could be seen as “conversion therapy”.

“I don’t think it’s about increasing the capacity to help more people”: The right to access care

Currently, young people can be waiting over three years to just have a first appointment with gender services. 

Everyone we heard from felt it is a priority to urgently reduce the waiting lists but there was concern that the guidelines would create additional barriers and delays to care. 

Under the proposals, a young person can only be referred to gender clinics via their GPs or NHS professionals. Both young people and parents shared negative stories from local doctors, with some having to deal with GPs with no knowledge of trans healthcare, while others had experienced outright hostility. 

The requirement for an additional assessment stage before joining the waiting list will not only create further delays, but also risks retraumatising young people seeking healthcare. 

One young person mentioned that the “whole process is a hoop-jumping and emotionally taxing exercise which is inevitably going to be a problem for those with additional needs” such as those who are neurodiverse. 

This view was echoed by a parent who told us how her child had “already had to speak to 10 or 12 people” about their body. “Why should I force my child to traumatise themselves just to get medication?”

“Not acting is not neutral: hearing your children saying I am, you know, whatever gender they are, and doing nothing, that’s where you need to go to social services”: The right to be heard 

These excessive delays and barriers are leading families, who can afford it, to seek out private healthcare for their young person.

The proposals encourage a GP to make a local safeguarding referral if a young person accesses medications through a private provider, putting families in the unenviable position of choosing between either listening to what their child wants and needs through private care, or being unable to access vital support from their GP. 

Far from reducing possible harm to trans young people, the guidelines are a dereliction of the duty of care towards an already marginalised community. 

Both young people and parents were very clear that the proposed changes reflect a complete lack of understanding of the experiences of trans people and those who support them. “If you are trans, or you have a loved trans person in your family, you get it. But if you don’t, you don’t. And that’s the problem” one parent told us.

We asked our young people if they could encourage the NHS to change one thing, what it be. “We know ourselves better than you ever will” was one response. 

It’s time we started listening to, trusting and believing trans and gender-diverse young people and their supportive families, placing their needs front and centre in the design of new healthcare services.

These proposals are not final and we have produced guidance to help those wishing to take part in the consultation. 

Regardless of the outcome, Mermaids will continue to campaign for a world where trans young people can thrive in every aspect of their lives. 

If you have found any of this information distressing and would like some support, call our helpline on 0808 801 0400.

NHS England has launched a consultation running from 20 October to 4 December on how the future youth gender services should run in the new clinics opening in Spring 2023.  

We have significant concerns about these proposals, which you can read about in our explainer blog, and in collaboration with Stonewall, Gendered Intelligence and Trans Learning Partnership, have now published guidance to help with your response.

The guidance takes you through the questions as they are on the response form, with key issues you may wish to raise in bullet points. We’ve also highlighted relevant research, as well as differences between this new specification and the previous specification where useful.

You can respond to the consultation via an online survey on the NHS England website any time before 4 December 2022.

Guidance for consultation responses: Interim service specification for specialist gender dysphoria services for children and young people in England (Phase 1 services)

Already completed the consultation? Great! Let us know you’ve done so by completing this form.

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.

Why now?

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?

  1. 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.
  2. 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.
  3. 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.
  4. 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“. 
  5. 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. 

What’s next?

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. 

If you find this news distressing and would like some support, do call our helpline on 0808 801 0400.