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Trans children, young people and their families have been faced with hateful narrative and misformation since the publication of The Cass Review on 10 April 2024. 

Media organisations and elected representatives hostile to trans youth have sought to misrepresent the report’s findings and call into question the validity of their experiences, and we are deeply disappointed, although not surprised, that Dr Cass’ own calls for compassion and respect have been completely disregarded. 

As a charity supporting trans youth and their families, our focus these past few weeks has been on reassuring those worried by the content of the report as well as the irresponsible way it is being interpreted. 

Since publication, we’ve met with Dr Cass and the review team alongside other LGBT+ support organisations to share concerns we’ve been hearing from our community. You can read about the questions they answered at the Kite Trust.

Our analysis is focused on what children, young people and families need to see in response to the review, and on how this could be delivered. 

You can find out more about what other organisations are saying about The Cass Review at Stonewall, Scottish Trans and TransActual. You can also read our short explainer giving more context to the Cass Review, and what it means. 

Overall analysis

While we have significant concerns about many aspects of the report, it recognises the existence of trans children and young people and rightly acknowledges what they have been saying for years: NHS services are comprehensively failing them. 

Young people we have spoken to are concerned about what they have read, including the desire to understand “why” young people are trans, and to place what feel like “limits” on gender expression, further pathologising and medicalising their identities. We share these concerns.

We are deeply frustrated with the lack of clarity throughout the report, which has enabled wilful misinterpretation and the spread of harmful misinformation. Clear and accessible language is vital, especially when services are operating in a context where there is significant hostility to and misconceptions about trans people, particularly in the media. 

“I don’t experience minority stress from ‘lots of different opinions’ – I experience minority stress because there is open and vitriolic conversation about how we don’t understand ourselves or our bodies, that we don’t deserve to exist, that we’re somehow evil and perverted or manipulated by something evil and perverted.”

The Cass Review team appears to have heard community concerns and agreed to publish more information providing clarity on the most troubling and misrepresented aspects of their report.

Beyond this, it is critical that NHS England and the Department for Health and Social Care (DHSC) listen to trans children and young people, their families and the trusted adults in their lives in shaping services, and resist pressure from those using the Cass Review in bad faith to further restrict access to healthcare and limit trans young people’s freedoms. 

Timely access to holistic, supportive care should be available close to home for all trans children and young people, including access to medical interventions such as puberty suppressing and cross gender hormones, and we will continue to campaign robustly for this.   

We call on NHS England to provide urgent upfront investment in these services, as well as the infrastructure and workforce to address the significant backlog caused by years of underinvestment and politicisation of the lives of trans children and young people.

Key concerns

Social Transition

The Cass Review does not, as has been misrepresented in the press, recommend a blanket ban on social transition for any age group, and specifically recognises the rights and agency of young people to present how they choose. Dr Cass calls for early access to support for young children and their families so that they can be supported around decisions relating to social transition. 

However, Dr Cass recognises that “there is no single definition of social transition” but then goes on to speak of “full” and “partial” social transition, without clarity.

As well as this lack of clarity, young people have told us that they are frustrated by the report’s desire to pinpoint a “cause” for trans young people to be open about who they are and are worried that it may be interpreted to limit social transition, particularly in schools.

“Why is there a failure to see that maybe just maybe if children socially transition and go onto medially transitioning it’s because they are trans!!!! And not because socially transitioning altered their development”

We have already seen this misrepresentation spoken in parliament, and we completely reject the words of Government ministers suggesting that being trans is anything other than a healthy and important way for young people to express themselves. 

It is vital that both NHS England and the Department for Education consider the full recommendations of the Cass Report in the development of services and updated guidance relating to trans young people. 

We will continue to advocate for supportive schools, where young people are able to express themselves authentically.

Puberty Suppressing and Gender Affirming Hormones

The report acknowledges the efficacy of puberty delaying treatment for some trans young people, while arguing that the evidence base is insufficient. The report also recognises that most young people receiving puberty suppressing treatment on the NHS aren’t doing so until it is too late for them to be effective (an average age of 15) as a result of long waiting lists and significant barriers to accessing care. 

The report also calls for “extreme caution” in prescribing gender affirming hormones to 16 and 17 year olds, which has already led to a review of prescription policy for all over 16s announced by NHS England, and the convening of a new multi-disciplinary team to oversee prescriptions for 16-17 year olds. We believe this is a knee jerk reaction from NHSE which may delay access to care.

There are questions about the way in which existing research has been used, evaluated and in some cases excluded from the review’s consideration. Dr Cass has agreed to provide clarity on this.

We have significant concerns about mandatory participation in research as a condition of access to treatment, and the way in which this area of gender care has been politicised far more than any other. 

We call on NHS England to reassure 16 and 17 year olds that their care will not be delayed, to speed up work on research trials, and to ensure that this is done so transparently, ethically and in line with international best practice. 

Services for Young Adults

Young people have told us that they are worried by suggestions in the media that Cass has recommended a block on transition until 25, particularly for neurodivergent young people. 

The report recognises that there are huge gaps in support for young people due to long adult waiting lists and the end of youth services at 18. 

We agree that no young person should be left without gender care at 18, and that there should be a seamless transition into adult services when it’s right for them. It’s also important that young adults who have been seen by children’s services are able to access the same care as their peers who first sought care as adults.

Instead of setting out what these services might look like, and committing to ensuring seamless support for young adults, NHS England immediately required adult services to cancel appointments for 17 year olds, many of whom have been waiting many years to access support. We call on NHS England to reverse this harmful decision and ensure support is offered to all 17 year olds who have been removed from children and young people’s waiting lists. 

NHS England must rapidly reassure young people and families that access to adult services remains unaffected while they develop and appropriately fund seamless follow-through service. 

Private Care

Free access to healthcare is a fundamental right. Due to the failure of the NHS to provide this to trans children and young people, many have been forced to access care outside of the NHS, at significant financial cost.

The review makes unclear recommendations about private and overseas care which may have implications for those using these services, both in their ability to access this care, and potentially accessing NHS services in the future.

We have heard from families where young people have been on NHS waiting lists for five or more years and have accessed private services both overseas and in the UK. They feel that the NHS has abandoned them, and that the Cass Report has provided NHS England and the DHSC with a blueprint to further restrict access to care for young people who have been failed by existing services.

Restricting access to these routes will likely result in people taking even more risky approaches, and reduce the likelihood that they will disclose this to supportive health professionals and trusted adults, increasing the physical, financial and safeguarding risks they face. 

The NHS and DHSC must ensure a non-punitive, harm reduction approach for all young people in these situations. This includes not applying restrictions to accessing NHS care and support for those who have used other forms of care and ensuring that primary and secondary care providers are equipped to provide harm reduction measures, such as monitoring.

Neurodivergence 

The Cass Report acknowledges that neurodivergence and mental health conditions are common among trans young people, and that these young people require a holistic approach to ensure that all their needs are supported.

However, there’s no clarity about why all young people should be screened for these conditions, what impact this will have on access to specialist gender care, or on waiting times. 

We are also concerned that the report implies that neurodivergent young people who are autistic are less trustworthy in articulating their trans identity than their neurotypical counterparts or that this capacity is limited until their “early 20s”. 

NHS England must clearly articulate that neurodivergence, disability or other health conditions will not impact on access to gender affirming care, including through longer waits caused by lengthy waiting lists for full assessment for other conditions. This includes ensuring clarity around the rights and agency of neurodivergent young people in line with Gillick competency.

What next?

We’re talking with colleagues across the LGBT+ and youth sectors about the actions we’re going to take to ensure timely, holistic and supportive healthcare for trans young people, and will keep you updated on our next steps. 

We’ll be talking more about what the Cass Review could mean for trans youth on our Instagram next week. In the meantime, to keep up to date with our healthcare campaign, join our mailing list and if you’d like to support our work, you can make a donation. 

If you need support, contact our helpline. We’re here for you Monday to Friday, 9am-9pm. 

Everyone deserves access to timely, supportive and holistic healthcare. However, across all of the UK, the NHS is failing trans youth, with appalling waiting lists of more than six years, virtually no first appointments offered for over a year, and increased politicisation of the support offered to children and young people. 

Trans youth tell us they want services which are accepting and respectful, which offer supportive spaces to explore their gender, and provide access to medical transition if and when they need it. 

The Cass Review, an independent review of NHS England gender services for children and young people, published today (Wednesday 10 April) after almost four years, echoes much of this and recognises the current system is failing trans youth. 

We are pleased the voices and experiences of trans young people appear to have been heard and respected, and we welcome Dr Cass’ calls for trans children and young people, and their families, to be “treated with compassion and respect”. We hope for the same, and for the sharing of clear, accurate information when discussing this topic.

However, we are concerned that some of the language in the report is open to misinterpretation and could be used to justify additional barriers to accessing care for some trans young people in the same way the interim report has been. We will publish our full analysis of The Cass Review in due course.

NHS England has published their immediate response to The Cass Review and written to all adult providers, explaining the changes they plan to make in the short to medium term. Very few of these will have an immediate effect on children and young people, and we will keep trans young people and their families informed about any changes that might impact them. 

In the meantime, we call on NHS England, and the NHS across the UK, to resist pressures from those who seek to limit access to healthcare, listen to trans youth directly, and act urgently to provide gender services which are timely, supportive and holistic. 

If you need support or have questions about what this might mean for yourself or your young person, please contact our helpline team. We’re here for you Monday – Friday, 9am – 9pm. 

NHS England’s updates today gave much welcomed clarity on the current and future provision of youth gender health services, but we remain concerned about the ever-growing waiting times. 

What has NHSE said? 

“Following the further advice Dr Cass’ provided in July 2022, NHS England set out plans for how it would start building a more resilient service by expanding provision and enhancing the focus on quality in terms of clinical effectiveness, safety, and patient experience. These plans were welcomed and supported by the Tavistock and Portman NHS Foundation Trust.

The first phase in these plans is to establish two new nationally networked services which, consistent with Dr Cass’ advice, will be led by specialist children’s hospitals.

These Phase 1 service providers (previously referred to as Early Adopter Services), will take over clinical responsibility for seeing children and young people on the national waiting list as well as providing continuity of care for the GIDS open caseload at the point of transfer. The Tavistock GIDS service itself will be decommissioned as part of a managed transition of the service to the new Phase 1 service providers.

One service – The Southern Hub – is being formed through a partnership between Great Ormond Street Hospital, Evelina London Children’s Hospital (part of Guy’s and St Thomas’ NHS Foundation Trust) and South London and Maudsley NHS Foundation Trust.

The other service – The Northern Hub – is being formed through a partnership between Alder Hey Children’s NHS Foundation Trust and the Royal Manchester Children’s Hospital (part of Manchester University NHS Foundation Trust).

These new services will be commissioned against a new interim service specification. A final version of the interim service specification will be published later in May 2023. This follows on from a period of formal public consultation on a draft specification which generated over 5,000 responses which have had to be carefully considered.

A single national transformation programme has been overseeing all aspects of the work to establish and commission the new services. The initial ambition was for the new services to commence in spring 2023. However, the complexity of the programme, including the need to design, commission and implement a new service model rather than simply transfer the existing service model across to the new providers, as well as the need to recruit and train a new clinical workforce has required revisions to the timetable. It is now anticipated that the early stages of service provision at the Southern Hub will begin in autumn this year (2023) – with the Northern Hub mobilising by April 2024.

During 2023/24 the GIDS at Tavistock will focus on providing continuity of care for their open caseload of around 1,000 patients. Continuing workforce capacity constraints within the GIDS, combined with the need to provide ongoing care for the large open caseload means that the Tavistock is currently not offering any new first assessment appointments. This will be kept under review but may remain the position until the Hubs begin seeing new patients. While this situation may be frustrating, particularly for young people who are towards the top of the waiting list, this is a temporary arrangement. The hubs will contact patients ahead of the services opening and as soon as practical, with offers of appointment dates.

In the meantime, the GIDS team will continue to work with all partners to consider how best to support patients whilst they wait to be assessed. Additionally, NHS England has commissioned new on-line support resources and materials for families of children and young people with gender incongruence and for professionals, and these will be made available in June.

To support the transition of service provision to the new providers, responsibility for managing the GIDS waiting list has now transferred completely from the Tavistock to NHS England, who now holds a single national waiting list from which the new providers will see children and young people. NHS Arden and GEM Commissioning Support Unit (CSU) is supporting NHS England in managing the national waiting list and has been supporting the Tavistock GIDS in managing the waiting list since August 2021. With a single national waiting list in place, NHS England will now write to all children and young people to confirm that we have their referral information, asking them to update this information where needed and to let them know what they can expect to happen next.

Placing the management of the waiting list with the CSU, has a number of advantages, including the ability to transfer children and young people from the waiting list to new providers in a managed way as the new services initially begin seeing patients and then as they ramp up capacity. The CSU will work with children, young people and their families to ensure that the information held is up to date to prevent delays in starting assessments.

A single waiting list has also enabled NHS England to begin to directly address some of the historical challenges in the pathway that have delayed or prevented children and young people progressing through a clinical pathway, such as the cohort of young adults aged 17 and over for whom a transfer to adult gender dysphoria services or to alternative local services has not happened. NHS England has also directly commissioned a specially convened multi-disciplinary team of children and young people’s mental health professionals and gender dysphoria specialists to jointly review referral information held in individual referral notes to identify cases where children or young people may benefit from additional local support while on the waiting list. In such cases the MDT is contacting GPs and local professionals to provide advice on appropriate sources of support.”

What does this mean?

The past 10 months have left young people and families distressed about their future or continued care, following the premature announcement of the closure of GIDS in “Spring 2023” to be replaced by two Phase 1 services, or Hubs. This has clearly not happened. 

NHSE’s update clarifies that:

  • GIDS will remain open into 2024, continuing to provide care to current patients
  • The Southern Hub of new services will open in Autumn 2023, seeing patients from the waiting list
  • The Northern Hub of new services will open in April 2024
  • Additional support will be provided for people on the 3+ year waiting list (via referrals to local support and online resources) in June 2023
  • The interim service specification (how the new Hubs will run), following last year’s public consultation, will be released at the end of May 2023

Kai O’Doherty, Head of Policy at Mermaids, said: “Mermaids welcomes clarity from NHS England on the current and future gender healthcare of young people in England, including the continued care for current patients at GIDS, and future services opening late 2023 and 2024. 

“The growth of the 3+ year waiting list remains a core concern for the young people we work with, however, and it is not good enough that no one will be taken off this list until later this year. Trans young people deserve better.” 

What happens next?

In addition to the new services opening, and an interim specification being finalised, the Cass Review’s work is continuing. This includes a set of research work they commissioned, and ultimately Dr Cass’ final report. This report will inform the new services, and the future Hubs planned in the future.

If you have any concerns about what this latest announcement means for you and would like to talk to someone, contact our helpline on 0808 801 0400. We’re here for you Monday to Friday, 9am-9pm. 

A paediatric doctor and parent of a trans child shares her view on the future of healthcare for gender diverse young people in England.

I have been a paediatric doctor for 10 years. I also have a primary-school age transgender child.

When my child first raised questions about their gender identity (“Mum, how do people know if they are a girl or a boy? Because I think I’m a boy”) I went looking for evidence to help me decide how to respond. 

After about six months of being supportive and non-judgemental while they continued to express their questions, my child asked to change their name and pronouns, haircut and clothes to reflect their male gender identity.

Following a further few months of making these changes at home, he made a full social transition at school and all other areas of his life, which was straightforward and joyful. I am confident that this is right for him now and in the future, however his exploration of gender identity turns out.

As an academic health professional I was dismayed to read the recommendations on social transition for pre-pubertal children in the NHS England commissioning documents that are currently out for consultation.

The document states that in most cases “gender incongruence does not persist into adolescence” and that we should be “mindful of the risks of an inappropriate gender transition and the difficulties that the child may experience in returning to the original gender role upon entering puberty” – discouraging a social expression of the child’s gender identity. 

What is really shocking to me is that the specification ignores a whole body of evidence that has been published in the last five years which directly contradicts their recommendation.

The specification relies on one source to support their claim about the low likelihood of “persistence” of transgender identity, the Endocrine Society guideline published in 2017. The evidence base indirectly cited in this guideline is made up of small and low-quality studies, including material published as far back as 1967 with titles including “the cissy boy syndrome”, focused on how to prevent homosexuality. 

However in 2022, we have evidence reporting the gender journeys of larger and more relevant cohorts of kids. One study found that 97.5% of socially transitioned North American kids (first assessed around eight years of age) retained a transgender identity at adolescence and after an average of five years follow-up.

Another study showed that even among the kids who “retransitioned”, social transition was primarily a positive experience, for example strengthening parent-child relationships through the demonstration of respect for the child’s chosen path.

We also now have evidence that the mental health of the teens who had been socially transitioned since childhood was similar to cisgender teens, especially important considering the poor mental health outcomes of transgender teens in non-affirmative settings. 

When making decisions on how to respond to my own child’s request for social transition, this was the most important factor I considered – how can I maximise and protect their mental health right now AND if their transgender identity is persistent? In my mind the answer is loud and clear – listen, trust, respect and affirm their expressed identity. 

Put simply, I could not parent my child in a respectful and loving way while simultaneously ignoring their expressions of gender identity. 

My child is incredibly happy in their social context and confident that their family and social community support them. They have learnt so much about themselves and felt empowered to form new friendships – things that will be of long-lasting value whatever they decide in the future. 

All parents want to do the best for their child and will look to the NHS for guidance. This specification must change to more accurately reflect the evidence in order to avoid further harm to our kids.

The consultation for the proposed specification runs until 4 December 2022. Mermaids has produced guidance to help you respond.

Two young trans people share their views on proposed changes to NHS healthcare services for trans and gender-diverse young people in England

We continue our series of blogs from our communities on the impact of the proposed guidelines with two young trans people, Jamie and Elijah, who have shared their views on the specification. 

The consultation on the proposed guidelines runs until 4 December 2022, and we have produced guidance on the consultation to help you respond. 

Jamie: “Social transition – it’s a lifesaver”

Social transition saved me as a teenager.

To some, it may seem unbelievable how such simple acts can have such a profound effect on someone’s life. For me, cutting my hair short started the long journey of being able to look myself in the mirror once more.

The new proposals argue for clinicians not to encourage social transition until a diagnosis of gender dysphoria has been made, citing Dr Hilary Cass’ statement that social transition is “not a neutral act” and fears over its long-term psychological impact.

To me, this is a huge step back in trans advocacy and self-determination. A clinical diagnosis to be permitted to cut your own hair short may seem preposterous. And that’s because it is! 

All individuals, trans or cis, go through a journey of self-discovery through their lives. Finding what it means to be authentically you is something inherent to the human experience, and it’s only once this authenticity is placed into a transgender context that it’s seen as something to be wary over, something to be medicalised. 

When I changed my name to a nickname, this was in a cis context, and thus was permissible, even encouraged. When I changed my name to what it is today, I was told to “think about my future”, and consider whether this was a “permanent” change that I really wanted. Silly considering how easy changing your name is here! 

The new proposals will undoubtedly cause harm to trans youth. Dr Cass was right, social transition isn’t neutral. It’s a lifesaver. 

Elijah: “a worrying outlook for what is to come for gender-diverse young people”

Holistic support is undoubtedly key for the well-being of young trans people and to make them feel supported there is a need for honesty and openness in communication from both sides. 

While young people using unregulated sources of medication is a concern, an approach that attempts to persecute the young person and their support system does nothing to reduce harm. 

The proposed guidelines state that safeguarding protocols will be initiated if a young person seeks medication outside the NHS which will make it difficult for young people to build trust with workers involved in their care.

The attitude towards social transition within the report is also concerning, painting it to be a process that requires medical approval rather than a gradual process of presenting in a way that makes you feel most comfortable. Young people know themselves better than a clinician who they only see once every few months.

I think it is ironic that while some claim that “allowing” children to be trans is depriving them of their childhood, in reality, the restrictions placed on trans young people create an environment where they are filled with fear, unable to simply enjoy their youth. 

Community support has been crucial in being able to manage the complex and overwhelmingly negative feelings I felt in relation to this consultation and has reaffirmed the importance of specific services for trans young people such as Mermaids. 

Although the specification seems to provide a worrying outlook for what is to come for gender-diverse young people in the UK, there is still hope and solidarity within the community, and we will push even harder for progress. 

Read more about the proposed changes in our explainer blog, and find guidance to help you respond here.

“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.

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.

We’re one of 10 organisations who have today (Thursday 4 August 2022) written to the Health Research Authority to express serious privacy and consent concerns with regards to the quantitative research approach proposed by the Cass Review.

Mermaids welcomes research into trans healthcare which aims to improve the quality and efficiency of the care provided to trans, non-binary and gender diverse children, young people and adults.

However, we want to ensure that any research carried out into our community is done in a way that is ethical and safe and does not put our community at risk of unnecessary harm.

You can read the letter here.

If you have questions about how this might affect you or your young person, please contact [email protected]. Any press enquiries should be directed to [email protected].

NHS Tavistock and Portman’s Gender Identity Development Service (GIDS), England’s sole provider of gender identity health services for children and young people, is closing its doors in Spring 2023. What does it mean for those currently accessing treatment, or on the waiting list to do so? We answer your questions…

Yesterday we heard some big news: England’s gender health services are set to expand, and those who are currently GIDS patients or on the waiting lists will transfer to the new service without additional delays.

If you had the unfortunate experience of reading misleading news headlines that “Tavistock is being shut down”, you might have felt fearful for the future gender-related healthcare for young people. So we are here to help try to break down the announcement, and reassure you that this might be, overall, quite good news! 

What’s happened?

On Thursday 28 July, NHS England announced that the current sole provider of gender identity health services for children and young people in England, NHS Tavistock and Portman’s Gender Identity Development Service (known by many simply as the Tavistock or GIDS), will be replaced in Spring 2023 by two regional centres – one in London, and another in the North West.

This news follows recommendations from Dr. Cass’ independent review of these services, which recognised – as we have for decades – that the current GIDS service is not up to scratch to cope with growing demand, and there is a need for better all-round care.

Once these two “Early Adopter” centres are up and running, the plan is for NHS England to expand the sites across the country, suggesting up to eight in total.

Dr. Cass seems to be unconvinced that there is enough evidence on the use of puberty blockers to be sure of how and when to prescribe them. NHS England will therefore start a “research protocol” where anyone prescribed puberty blockers will also be part of a long-term study to build this evidence base.

What does this change?

In the short term – nothing. Anyone waiting to be seen by GIDS, or currently a patient with them, will continue to be so, with no additional delays, according to NHS England. Blockers and hormones can still be prescribed as usual.

Anyone waiting to be seen by GIDS, or currently a patient with them, will continue to be so, with no additional delays”

In the long term, we’re hopeful that we might finally be seeing the start of the root and branch system change we have long been calling for. Including: services closer to where you live, shorter waiting times because there are more people and services, and more consistency in treatment across the country.

What are the pros and cons?

From what Dr. Cass has proposed, we are cautiously optimistic of the benefits this model could bring, including:

  • More capacity in gender healthcare services, meaning shorter waiting times (currently at two and a half years for a first appointment)
  • Regional services throughout England, which will bring support closer to home
  • A more holistic approach to care, connecting different local services through a shared care model, rather than expecting patients to connect the dots across different types of medical support
  • The outlined approach to care addresses key issues we’ve raised continuously, including: support for those on the waiting list, a diversity of pathways recognising each person has different needs and desires, and embedding support from the third sector
  • A national network to build capacity, understanding and best practice across the regional services should help bring more consistency across services.

Of course, it’s not all good news, and we do still have some concerns. We will need to wait for the details on some parts, especially in making sure the transfer to new services doesn’t leave anyone worse off.

We are also not happy with the potential idea that anyone accessing puberty blockers must be part of long-term research – we think there needs to be an opt-out option as no one should be required to be studied in order to access healthcare. 

What does this mean for gender identity services in the rest of the UK?

It’s important to remember the Cass Review, and these proposed changes, are specific to NHS England, so services in Scotland, Wales and Northern Ireland will not be directly impacted.

What happens now?

As always, we will advocate for the needs of trans, gender-diverse and non-binary children and young people and their families throughout this process. Trans people and their families must be involved throughout, and waiting lists must not lengthen because of these proposals.

We will engage meaningfully with policy-makers in this area, centring the voices of our communities, and will continue to fight for what we need to fix this broken system. 

If you’ve got more questions about what this news means for you or your young person, please contact our helpline team on 0808 801 0400 or email [email protected]. 

The Cass Review’s Interim Report, published 10 March 2022, clearly recognises that NHS England’s current healthcare model is not fit for purpose and that trans children and young people deserve, but are not currently receiving, the same standard of care as everybody else. 

Any healthcare pathway has to be informed by those it is there to help, here being trans, non-binary, gender diverse and/or gender exploring children and young people. We read the report from this perspective and in doing so we see these interim recommendations as a positive step toward much-needed change.

We do recognise however, that this is an interim report – those claiming this as a “win” or “lose” moment, do so prematurely. We are committed to continue working with the review team to ensure the voices of young trans people are at the centre of this work.

We are pleased to see recommendations that echo some of the calls our community has been making, including to: 

1. Establish regional centres for direct service delivery, thereby creating more services closer to where we live; 

2. Significantly increase training for healthcare professionals at all levels and addressing long-term workforce issues, thereby addressing capacity issues;

3. Creating consistency in a clinical approach which is open, respects the experiences of the young person, and prioritises the consent of the young person, thereby avoiding a “postcode lottery” of care;  

4. Improve data collection to help inform the pathway’s future development. 

At Mermaids, we know all too well how inadequate the healthcare system is for trans and gender-diverse young people. We are pleased to see that the Cass Review doesn’t shy away from emphasising the need for a system-wide response to reduce current waiting times of over three years, that the Review emphasises that puberty blockers are not experimental, as well as acknowledging that “doing nothing cannot be considered a neutral act” (p. 63).

It is worth addressing confusion on what is meant by affirmative care. Mermaids supports both national (British Psychological Society) and international (WPATH) guidance and best practice on the use of an affirmative approach to trans healthcare, which simply means supporting a young person’s understanding of who they are while taking an exploratory approach. The two are not mutually exclusive. In our view, this aligns with the interim report’s approach of supportive, exploratory intervention. We welcome clarification from the Cass Review team on this.

What now?

The Interim Report is an important first step towards a complete overhaul of the current gender identity healthcare model. We know that there is much more to be done and transformation cannot happen overnight. We want to reassure trans, non-binary and gender diverse young people and their families that we are working hard to ensure your voices and experiences are heard throughout the process. We will continue to work with the Cass Review team and are hopeful the final recommendations will bring about the meaningful change that is so drastically overdue.