What is happening?
There are significant differences in Clinical Comissioning Group (CCG) referral rates across England. Analysis of referrals by NHS CCGs found that some CCGs are referring under 18s to the Gender Identity Development service at more than twice the referral rate for England as a whole in 2018-19. One, Blackpool, has a referral rate three times the national rate.
|CCG (2018)||2018–2019 referrals||Referrals per 100,000 under 18s||Rate relative to England overall||Probability that disparity is due to chance|
|NHS NORTH EAST LINCOLNSHIRE CCG||27||79||205%||.001|
|NHS SOUTH DEVON AND TORBAY CCG||42||81||210%||.000|
|NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG||29||81||211%||.000|
|NHS GREAT YARMOUTH AND WAVENEY CCG||35||82||214%||.000|
|NHS BRIGHTON AND HOVE CCG||42||82||215%||.000|
|NHS BLACKPOOL CCG||35||122||317%||.000000007|
The analysis here has been updated since the Times article to use 2017 ONS population data to more accurately reflect the boundaries of CCGs existing in April 2018. This has led to an adjustment to referral rate but only slight change to ranking.
The data was compiled by Nikki da Costa and analysed by Michael Biggs, Associate Professor in Sociology, University of Oxford.
What is happening nationally?
There has been a steep national increase in referrals and dramatic change in who is being referred. Those referred to the NHS Gender Identity Development Service provide a snapshot of the broader pattern.
- 138 under 18s were referred in 2010-11. 2383[i] in 2020-21.
- In 2011, only one CCG referred more than four children (5), the majority referred none
- Two thirds are teenage girls, with no prior history of gender dysphoria before puberty. A decade ago it was largely boys who started to experience gender dysphoria in early childhood.
- 35% referred have mild to severe autistic traits or other types of neurodiversity
- Majority are same-sex[ii] attracted or bisexual raising concerns of internalised homophobia – that it is easier to ‘be trans’ than it is to be gay or lesbian
- Looked after children are over-represented[iii]. They make up 0.58% of the general population but 4.9% of GIDS referrals. Adopted children account for another 3.8% of referrals
- Many have complex mental health histories prior to referral
No one knows what has caused this increase nor why the children referred are very different from a decade ago. The Independent Cass Review, commissioned by the NHS, found a profound lack of knowledge about the young people currently presenting with gender dysphoria, and how they fared after receiving treatment.
Why is this an issue?
If a child has gender dysphoria (discomfort with the sex of their bodies) potentially irreversible medical treatment may follow. The demand for medical intervention by under 18s is growing.
A pathway[iv] may consist of early placement on puberty blockers, with unknown effects on brain and bone development, progression to cross-sex hormones, with irreversible changes such as breaking or deepening of the voice, development of breast tissue, temporary or even permanent infertility, and some to surgery age 18, including removal of breasts or testes and penis[v]. Care for under 18s can be provided both on NHS, through the Gender Identity Development Service, and increasingly in private gender clinics. Worryingly hormones are also being bought on the internet.
There is increasing awareness that gender-related distress may be a response to many psychosocial factors, often connected to puberty, and may include social media and peer group influence, rather than a simple explanation that the child is just ‘trans’. These factors need exploring given the consequences of pursuing a medicalised pathway. The need for caution has been echoed by France’s National Medicines Agency[vi] and Sweden’s National Board of Health and Welfare[vii].
Significant and unexpected geographical differences highlight our lack of knowledge.
Nikki da Costa
These are some of the questions we suggest need asking:
- Given the overrepresentation of looked-after children being referred to the Tavistock GIDS (as referenced in the Cass interim report) is the CCG in a deprived area with an above average number of children in care?
- What trans schools guidance does the local authority recommend and does it teach children that the criteria for being a boy or a girl is ‘gender identity’, not sex?
- How active is the local authority in pushing the idea of gender identity in schools? (for example in schools admission forms, pupil surveys, Pride or LGBTQ+ clubs in schools etc)
- Is there a local trans activist organisation or individual activist in a position of influence?
- What local or national trans and LGBTQ+ support groups for children and young people are operating in the area?
- Is the local NHS Trust a Stonewall Diversity Champion or otherwise affiliated with organisations promoting gender identity ideology?
- How does the referral rate for gender dysphoria compare with the rate of general child and adolescent mental health referrals to local CAMHS services?
- Other factors such as ethnic mix, religious beliefs, political party support, socio-economic status.
- Are there any unique or confounding factors within any area ?
We will follow up with a post examining some of these factors.
The political view would be celebration: trans kids feel safe to ‘come out’ in these areas.
The clinical view would be concern: above average numbers of children are distressed about their gender and reject their bodies, often with underlying, pre-existing mental health problems.
We need researchers to analyse the factors which may be fueling the current gender dysphoria contagion affecting so many adolescents, in particular teenage girls.
We hope this regional research will be a starting point for further investigation and we thank Nikki Da Costa and Michael Biggs for all their work in compiling and analysing the data.
[ii] GIDS data: only 8.5% of natal girls referred in 2012 were attracted to boys
[iii] Referenced in Cass Review, Interim Report, page 32: Matthews T, Holt V, Sahin S, Taylor A, Griksaitis (2019). Gender Dysphoria in looked-after and adopted young people in a gender identity development service. Clinical Child Psychol Psychiatry 24: 112-128. DOI: 10.1177/1359104518791657.
[iv] NHS website – Treatment of Gender Dysphoria – https://www.nhs.uk/conditions/gender-dysphoria/treatment/
[v] There is “very limited research on the sexual, cognitive or broader development outcomes”[v] of this treatment. Cass Review: an independent review of gender identity services for children and young people: Interim Report, p19