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UK: Doctors will no longer encourage gender-curious children to use preferred pronouns or dress as opposite sex under NHS guidelines

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  • Pathfinder
    Interim service specification for specialist gender dysphoria services for children and young people – public consultation

    Closes 4 Dec 2022

    Opened 20 Oct 2022

    NHS England Specialised Commissioning


    NHS England commissions specialised services for people with gender dysphoria, and it is holding this consultation to seek views on a proposed interim service specification for services for children and young people with gender dysphoria.

    Once agreed, this interim service specification will be operational for a limited time only until a new service specification is formed in 2023/24 that will be used by a new configuration of regional providers.

    In order to complete this consultation, please review the following documents:
    The public consultation will run from 20 October to 4 December 2022.

    Why your views matter

    NHS England is committed to working with patients, patient groups and other stakeholders in the development of its commissioning of services. This public consultation is an opportunity to check whether proposals are right and supported, whether the public understand their impact, and to identify any alternatives before decisions are made.

    Give us your views

    Online Survey


    Public consultation
    Interim service specification for specialist gender
    dysphoria services for children and young

    20 October 2022


    The term used to describe a discrepancy between birth-assigned sex and gender
    identity is ‘gender incongruence’. Gender incongruence is frequently, but not
    universally, accompanied by the symptom of gender dysphoria: “a disorder
    characterized by a strong and persistent cross-gender identification (such as stating
    a desire to be the other sex or frequently passing as the other sex) coupled with
    persistent discomfort with his or her sex”.

    There is currently only one provider of specialist services for children and young
    people (up to the 18th birthday) with gender dysphoria in England – this is the
    Gender Identity Development Service (GIDS) for children and adolescents, delivered
    by the Tavistock and Portman NHS Foundation Trust in London.

    The GIDS is also directly commissioned by NHS Wales, and the changes described
    in this document will impact on patients who are the commissioning responsibility of
    NHS Wales.
    Interim service specification: the case for change

    In September 2020, NHS England commissioned an independent and wide-ranging
    review of gender identity services for children and young people. The Review, which
    is ongoing, is being led by Dr Hilary Cass, past president of the Royal College of
    Paediatrics and Child Health. It was established in response to a complex and
    diverse range of issues including:

    1. A significant and sharp rise in referrals

    In 2021/22 there were over 5,000 referrals into the Gender Identity Development
    Service (GIDS) run by the Tavistock and Portman NHS Foundation Trust. This
    compares to just under 250 referrals in 2011/12.

    2. Marked changes in the types of patients being referred which are not well

    There has been a dramatic change in the case-mix of referrals from predominantly
    birth-registered males to predominantly birth-registered females presenting with
    gender incongruence in early teen years. Additionally, a significant number of
    children are also presenting with neurodiversity and other mental health needs and
    risky behaviours which requires careful consideration and needs to be better

    3. Scarce and inconclusive evidence to support clinical decision making

    This has led to a lack of clinical consensus on what the best model of care for
    children and young people experiencing gender incongruence and dysphoria should
    be; and a lack of evidence to support families in making informed decisions about
    interventions that may have life-long consequences.

    4. Long waiting times for initial assessment and significant external scrutiny
    and challenge surrounding the clinical approach and operational capacity at

    This has contributed to the current service being unable to meet the scale of rising
    demand and concerns being raised by healthcare regulators about the standard of

    Next steps

    In February 2022, Dr Cass published an interim report in which she set out initial
    findings and advice from her Review. She emphasised the need to urgently move
    away from the current model of a sole provider, and to establish regional services
    that work to a new clinical model that can better meet the holistic needs of a
    vulnerable group of children and young people. She began to describe the need for
    these new services to work as networked centres that connected with other local
    services including children and young people’s mental health services and primary
    care to support all a patient’s clinical needs.

    In July, Dr Cass gave further advice on the core components of this model. You can read the advice in full here.

    In summary, she has said:

    • ‘Regional centres should be led by experienced providers of tertiary paediatric
    care to ensure a focus on child health and development, with strong links to
    mental health services. These will generally be specialist children’s hospitals.

    • ‘They should have established academic and education functions to ensure
    that ongoing research and training is embedded within the service delivery

    • ‘The services should have an appropriate multi-professional workforce to
    enable them to provide an integrated model of care that manages the holistic
    needs of this population’.

    • ‘Staff should maintain a broad clinical perspective to embed the care of
    children and young people with gender uncertainty within a broader child and
    adolescent health context’.

    • In view of the uncertainties surrounding their use, consideration should be
    given to the rapid establishment of the necessary research infrastructure to
    prospectively enroll young people being considered for puberty blocking drugs
    What are the proposed changes?

    The interim service specification proposes the following changes and points of
    clarification over the current service specification.

    1. Composition of the clinical team – substantive change

    The current service specification for GIDS describes that the service is delivered
    through a specialist multidisciplinary team with contributions from specialist social
    workers, family therapists, psychiatrists, psychologists, psychotherapists, paediatric
    and adolescent endocrinologists and clinical nurse practitioners. The new interim
    service specification proposes to extend the clinical team so that it is a more
    integrated multi-disciplinary team that, in addition to gender dysphoria specialists,
    will include experts in paediatric medicine, autism, neurodisability and mental health.
    2. Clinical leadership – substantive change

    The current service specification for GIDS does not describe criteria for the clinical
    lead for the service. The new interim service specification proposes that the clinical
    lead for the service will be a medical doctor.
    3. Collaboration with, and support for, referrers and local services –
    substantive change

    The current service specification for GIDS describes a tiered approach for
    progression through the clinical pathway: the first tier involves meetings between the
    GIDS team and local professionals involved in the care of the child or young person
    and the second tier involves the child or young person accessing local services for
    mental health needs with GIDS offering advice to local services.
    4. Referral sources – substantive change

    The current service specification for GIDS states that referrals can be made by staff
    in health and social services, schools, colleges of further education and by voluntary
    organisations. The new interim service specification proposes that referrals may be
    made by GPs and NHS professionals.
    5. Social transition – clarification

    The current GIDS service specification acknowledges that social transition in prepubertal
    children is a controversial issue, that divergent views are held by health professionals, and
    that the current evidence base is insufficient to predict the longterm outcomes of complete
    gender-role transition during early childhood.

    The interim Cass Report has advised that although there are differing views on the
    benefits versus the harms of early social transition, it is important to acknowledge
    that it should not be viewed as a neutral act. Dr Cass has recommended that social
    transition be viewed as an ‘active intervention’ because it may have significant
    effects on the child or young person in terms of their psychological functioning.
    In line with this advice, the interim service specification sets out more clearly that the
    clinical approach in regard to pre-pubertal children will reflect evidence that in most
    cases gender incongruence does not persist into adolescence; and that for
    adolescents the provision of approaches for social transition should only be
    considered where the approach is necessary for the alleviation of, or prevention of,
    clinically significant distress or significant impairment in social functioning and the
    young person is able to fully comprehend the implications of affirming a social

    Endocrine Interventions

    Building the research protocol

    The interim service specification reads:

    "Consistent with advice from the Cass Review highlighting the uncertainties
    surrounding the use of hormone treatments, NHS England is in the process of
    forming proposals for prospectively enrolling children and young people being
    considered for hormone treatment into a formal research programme with
    adequate follow up into adulthood, with a more immediate focus on the
    questions regarding GnRHa. On this basis NHS England will only commission
    GnRHa in the context of a formal research protocol. The research protocol will
    set out eligibility criteria for participation.”

    In due course NHS England will share details of this work, including plans for how
    stakeholders and the public will be engaged and consulted on eligibility criteria.

    Placing the use of GnRHa in the context of clinical research will have several
    important benefits:

    • It responds directly to Dr Cass’ advice that ‘Without an established research
    strategy and infrastructure, the outstanding questions will remain unanswered and
    the evidence gap will continue to be filled with polarised opinion and conjecture,
    which does little to help young people, and their families and carers, who need
    support and information on which to make decisions’. In this respect the NHS has
    the opportunity to make a major international contribution to the evidence base in
    this area.

    • Secondly, it will ensure that there is greater transparency for children and their
    parents / carers around the uncertain clinical benefits and longer-term health
    impacts surrounding their use.

    • Thirdly, it will further strengthen the consent and information sharing process to
    support informed decision making by young people.

    Unregulated drugs

    The current service specification for GIDS states that GIDS does not offer shared
    care with private clinicians, and that in cases where puberty blocking drugs or
    hormone drugs are prescribed or accessed outside the service, the GIDS will make
    the young person and their family aware of the risks, contraindications and any
    irreversible or partly reversible effects of any interventions, and will be unable to
    provide ongoing clinical supervision for the management of these interventions.

    The proposed interim specification reads:

    “Children, young people and their families are strongly discouraged from
    sourcing GnRHa and masculinising / feminising hormone drugs from
    unregulated sources or from on-line providers that are not regulated by UK
    regulatory bodies. In such cases The Service will make the child or young
    person and their family aware of the risks, contraindications and any
    irreversible or partly reversible effects of the drugs and will advise the GP to
    initiate local safeguarding protocols.

    “Should a child or young person access GnRHa from unregulated sources or
    unregulated providers The Service will not assume responsibility for
    prescribing recommendations nor will it enter into shared cared arrangements
    in these circumstances.

    “Where a child or young person has obtained masculinising / feminising
    hormones from an unregulated source (such as the internet) The Service will
    not accept clinical responsibility for management of the endocrine

    The reason for the revised wording is to provide greater clarity and retain and
    strengthen current safeguards. Senior clinicians have advised NHS England on the
    need for the new interim service specification to have much clearer wording in this
    regard so that the interim service specification is less open to interpretation, so that
    young people, families and professionals are clear on the approach that will be
    adopted by the NHS in such cases.

    Leave a comment:

  • UK: Doctors will no longer encourage gender-curious children to use preferred pronouns or dress as opposite sex under NHS guidelines


    Doctors will no longer encourage gender-curious children to use preferred pronouns or dress as opposite sex under NHS guidelines

    NHS to consider risks of social transition in youth questioning gender identity
    Social transitioning can include changing name, pronouns, and crossdressing
    New guidelines say it can have significant effects it on a child's psychology
    They also say most children will not commit to gender changes in their teens

    By John Ely Senior Health Reporter For Mailonline
    Published: 13:16 EDT, 21 October 2022 | Updated: 13:16 EDT, 21 October 2022

    Doctors will no longer encourage gender-curious children to use the pronouns of their preferred identity.

    New NHS draft guidelines will also discourage the act of children dressing in clothes of the opposite sex.

    Health chiefs say 'social transitioning' should be no longer be viewed as a 'neutral act' due to the significant effects it may have on a child's psychology.

    Social transitioning refers to a person being treated as the gender different to their biological sex but without medical interventions like controversial puberty blockers or hormones.

    This can see people change their name, their pronouns and dress in clothes usually associated with their opposite sex.

    Their family, friends and school are encouraged to be supportive of this process.

    At the extreme end of the scale, social transitioning can see people controversially use the bathrooms or changing facilities of their believed gender identity.

    But now NHS England's draft approach calls on clinicians to recognise most cases of 'gender incongruence' in children are just a phase...