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Following is Transgender Trend’s response to the NHS England Children and Young People’s Gender Service Specification.

The public consultation is open to everyone; please do respond. The deadline is this Sunday November 2nd.

You can respond here.

The gender service specification is here. The clinical commissioning policy for cross-sex hormones is here.

We are pleased that the new gender service specification is based largely on holistic psychotherapeutic care but we have questions about the purpose of this treatment and the fact that it could lead to a medical pathway. We don’t agree with the provision of puberty blockers or hormones to minors and we think NHS England needs to do more to safeguard children from the harmful ideas that have led to medicalisation of gender non-conformity.

Please take what is useful from our draft submission and respond in your own words as far as possible. You don’t have to write your comments for every question so if you have little time Question 5d is the most important to register opposition to a medical pathway.

3. To what extent do you support the inclusion of the holistic assessment of needs (Appendix A in the service specification)?

Partially agree

The way assessment is framed in Appendix A suggests a fixed diagnosis of ‘gender incongruence’ with no consideration of causative factors that may present as ‘gender incongruence’ but indicate a diagnosis unrelated to gender. This does not allow space for true ‘differential diagnosis.’

Assessment should not be only a process of ‘ruling out’ other potential diagnoses, but allowing for other possibilities. There are problems with both  ICD11 ‘gender incongruence’ or DSM5 ‘gender dysphoria’; neither of these are medical diagnoses with clear rationale for medical intervention. True ‘open-minded’ holistic formulation is not possible while done only in relation to either of these two problematic models.

This section reads as though the child will be helped to manage ‘co-occurring/contributory elements’ in order to improve their ‘psychological functioning, sense of wellbeing and quality of life’ as a trans person, without challenging or examining the child’s claimed self-diagnosis as ‘trans.’

In stating ‘gender incongruence is not considered to be a mental health condition’ the guidance limits and restricts individualised holistic understanding, in adherence to a set idea, precluding open investigation and curiosity. ‘Identifying and treating mental health difficulties’ becomes an exercise in paving the way for a happier ‘transition’ – ‘so the child/young person is able to function and make complex decisions’ – rather than examining the whole picture and the child’s understanding.

If ‘gender incongruence’ is neither a mental or physical health problem, it doesn’t need medical treatment. Gender non-conformity (described in ICD11 as gender incongruence) is clearly non-pathological. But a child identifying as ‘trans’ as a maladaptive coping strategy in response to bullying or social ostracisation is a very different proposition. The basic definitions upon which treatment is based must be clarified.  

The guidance must be stronger on safeguarding. The point ‘transphobic bullying in school and in other settings’ comes first, but does not define the term ‘transphobic.’ Use of the term assumes the child is ‘trans’ and interprets ‘bullying’ through this lens. As parents are accused of ‘transphobia’ if they don’t affirm their child’s identity, use of this term is problematic and indicates bias.

It is irrelevant that there are ‘different views on the benefits versus the harms of childhood social transition’, only the evidence of the risk/benefit profile is relevant. It is outside the NHS’s authority to advise social transition, as this would prescribe the behaviour and affect the rights and safety of other children within a school setting. The point must be made clear to the child and the parents that the clinician cannot recommend social transition for this reason alone.  

The section ‘Education, peer relationships and social context’ is inadequate. By far the greatest pressure on children comes from activist organisations, online social media platforms and mainstream media, funnelled through schools and peer groups. Factors such as the teaching of ‘gender identity’ as fact in schools; displays, flags, lanyards and posters in NHS hospitals and GP surgeries; and cultural messages, tailored specifically to be attractive and alluring to children, elevating and celebrating the ‘trans child’, are omitted.

4. To what extent do you agree with the approach to the management of patients accessing prescriptions from un-regulated sources as explained above?

Agree

Appendix A in the clinical commissioning policy for cross-sex hormones, which allows a continuation of prescribing under certain conditions, contradicts this section. This should be immediately withdrawn and the policy in the service specification tightened up. These are dangerous drugs to give to children without proper oversight, and in all circumstances where a child is accessing these drugs from either unregulated or private clinics outside NHS protocols it should be seen as a serious safeguarding issue.

The service specification should make it absolutely clear that it is the clinician’s responsibility to report any instance of a child accessing these hormones, and to refer to the relevant authorities, including social services where there is evidence of an adult procuring these drugs for a child.

5. To what extent do you support the following other proposed changes to the specification as described above:

a. The description of the role and function of the National Provider Network. 

Partially agree

The National Provider Network is essential for consistent data collection, audit and the development of shared standards, training and education. The NHS must ensure that the Network is protected from activist infiltration. Safeguards must be built in to prevent the kind of intimidation and silencing culture experienced at the Tavistock GIDS and which is endemic in this area of healthcare. There must be a clear whistleblowing procedure and policy.

Section 8.1 of the March service specification states:

‘In addition, well-structured research programmes will be developed through a National Children and Young People’s Gender Incongruence Research Oversight Board to include for example: epidemiology; prediction; the course of gender querying; and outcomes of psychological treatments to reduce distress.’

Why has this been cut from the August version? This is essential research that should be done before offering any medical pathway. Epidemiology is foundational to understanding this area; the current state of ignorance, as acknowledged in the Cass Review, is unacceptable and inadequate for the provision of safe patient care.    

b. The description of the arrangements for data collection, audit and evaluation.

Partially agree

We agree that data must be collected for the whole cohort of children, ‘including for those for whom, following assessment, it is determined there would not be benefit from intervention by the Service.’ This is vital information.

‘Continuous data collection, reporting and audit to support the NHS in developing a better understanding of the relevant patient cohorts’ is necessary, as stated in the March version of the Service Specification but has been inexplicably cut from the August version. A better understanding of the cohort is a basic requirement, particularly the ‘rapid onset’ group about which little is yet known.

The statement in the March version of the Service Specification ‘It is important that the opportunity is taken to gather further evidence on the safety, potential benefits and harms of medical interventions’ has been changed in the August version to ‘It is important that the opportunity is taken to build further evidence on the safety, potential benefits and harms of both medical and non-medical interventions.’

We agree with this change, which is in line with the Cass Review. More evidence is needed for non-medical interventions, including doing nothing, and we believe this must be prioritised. The evidence for the intrinsic harms of medical intervention is already known, and we do not believe studies to show further evidence of the exact degree of harm are either necessary or ethical.

c. The role of the Children and Young People’s Gender Service in leading a network of Designated Local Specialist Services.  

Partially agree

This is a vital role for the Service but it is dependent on training. This should be an urgent priority. NHS England must ensure that paediatric services are fully-aligned with the recommendations of the Cass Review and that therapists who practice a ‘gender affirmative’ or ‘social justice’ approach are weeded out of children’s services.

CAMHS premises should be free of activist-related paraphernalia such as posters of the ‘Genderbread Person’, trans flags and lanyards etc and therapists must be fully supported by NHS England to be neutral and professional according to normal standards of care. NHS England must do more to advocate for normal standards of therapy in this area and to educate both professionals and policy-makers that this is not ‘conversion practice.’

However, it is stated ‘The approach for onward referral to a paediatric endocrinology clinic for the purpose of assessment for suitability for exogenous hormone intervention is described in NHS England’s published clinical commissioning policy.’

This is Cass Recommendation 8: NHS England should review the policy on masculinising/feminising hormones. The option to provide masculinising/feminising hormones from age 16 is available, but the Review would recommend extreme caution. There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18.

But the clinical commissioning policy states ‘Gender Affirming Hormones (masculinising or feminising hormones) (GAH) are available as a routine commissioning treatment option.’

In their response to the Cass Review final report NHS England states ‘In order to support the providers in following your advice we have established a national multi-disciplinary team (MDT) that will review and need to agree all recommendations for hormone intervention.’

But the Service Specification states ‘The role of the National MDT in considering recommendations for assessment of suitability for exogenous hormones is described in the clinical commissioning policy.’

The Clinical Commissioning Policy states that the MDT must agree on ‘the suitability of the individual receiving GAH based on the consideration of these eligibility and readiness criteria.’ The eligibility and readiness criteria described in the policy includes ‘Associated difficulties such as a psychotic episode, drug addiction or self-harming are not escalating.’

This makes a mockery of the careful and thorough mental health evaluations set out in the Service Specification. To what end will these evaluations be carried out and of what value are they if they can be simply overridden as long as a child’s symptoms are not getting worse?

The clinical commissioning policy for cross-sex hormones is not fit for purpose and should not be used until a full review, similar to the puberty blockers review, is carried out. It cannot be right that the updated Service Specification uses an out-of-date and wholly inadequate clinical commissioning policy that contradicts and undermines both the Service Specification and Cass recommendations.

d. The inclusion of endocrinology as a core function within the Children and Young People’s Gender Service’s Multi-disciplinary Team.

Partially Disagree

The Service Specification states that the MDT’s ‘shared expertise and decision making’ underpins referrals onto a medical pathway, including for the purpose of initiation of hormone treatments ‘should that be mandated in NHS England’s clinical commissioning policy at the time.’

It is not adequate or acceptable that the Service Specification is based on crucial work that the NHS has failed to complete.

The Clinical Commissioning Policy was largely determined before the final Cass report and the systematic reviews of GAH by both NICE and the Cass Review team. It is outdated and dangerous.

The Service Specification states ‘Puberty suppressing hormones are not a routinely available intervention because of the limited evidence about safety, risks, benefits and outcomes.’

Systematic reviews found exactly the same inadequate evidence for cross-sex hormones. These should also not be routinely available for under-18’s for the same reasons.

The role of endocrinologists within the MDT should be educational and advisory on the harms of disrupting a child’s healthy endocrine system. This is crucial information for the MDT as well as children and parents if they are to give fully-informed consent to treatment.

e. The separate pathway for pre-pubertal children.

Partially agree

The separate pathway for pre-pubertal children makes sense as historically this was the group referred to gender clinics, and is consequently the group we know most about, particularly in terms of desistance/persistence rates. Conversely, the ‘rapid onset’ or post-pubertal group is new and unprecedented and little is yet known about the etiology of this group.

Cass expressed concerns about early social transition, so a separate pathway that enables parents to obtain accurate information and advice on this subject, rather than the misleading ‘advice’ of activists, would be helpful.

Some of the language used in the Service Specification, however, is concerning. For example: ‘Changes in gender expression whereby the child or young person presents to others in line with societally expected indications of gender identity different to that of their natal sex is known as ‘social transition’.’

This doesn’t make sense. There are no ‘societally expected indications of gender identity’, there are socially expected stereotypical behaviours of boys and girls. Applying a ‘gender identity’ lens to little children suggests an adult ideological interpretation of a child’s behaviour.

The phrasing implies that a child who is behaving in non-stereotypical ways for their sex is ‘socially transitioning.’ This is not an appropriate framing of childhood behaviour. It confuses childhood exploration/personality traits as linked to the concept of ‘gender identity’ and being ‘transgender’. This is developmentally inappropriate. Confusing the expression of personality and gender non-conformity in children with the idea of being trans is an activist view.

It is crucial that clinicians in the new service do not take this activist approach towards children. Training in this area, based on child development, will be critical for both clinicians and local specialist services. Safeguarding is key. It is adults who ‘socially transition’ children by pretending they are the opposite sex. A child may believe this, but it is the adults who reinforce the belief, and it is the clinician’s responsibility to report any safeguarding concerns about a family that is doing this.

Ideally, little children should not be referred to gender services as this is developmentally inappropriate. However, given the current activist influence on parents, it is likely that some will turn to gender services for help. The role of the service must be to advise against social transition and to refer on to the relevant authorities/services if there are safeguarding concerns or other reasons to do so.

6. The proposed provider-reported metrics aim to help monitor and assess the quality of the service. To what extent do you agree with the inclusion of the metrics?

Partially disagree

It is concerning that there are no outcome measures for the new service. Results need to be measured against outcome measures to have any meaning. Metrics must include long-term outcomes, not just short-term outcomes which may be misleading. Long-term follow-up by sex, bone density, fertility, adverse health outcomes and regret/detransition rates must be measured, which necessitates a single governance framework between child and adult services.

The metrics are focused on process or short-term patient satisfaction. This is not adequate, and short-term results are likely to mislead. The initial ‘honeymoon period’ of patient satisfaction is well-documented and research indicates that regret takes around eight years to kick in. If short-term patient satisfaction results give the green light to continue with medical interventions the service will continue to facilitate long-term harm and regret for an as-yet unknown number of children. Results of the data-linkage study are critical to build the long-term evidence base before NHS England continues to offer hormonal interventions.

7. Are there any other changes or additions to the revised service specification that should be considered?

Yes

Where is the information about a bridging service for 17 – 25 year-olds between child and adult services? (Recommendation 23 of the Cass Review). This is a key development of the service, given that the Levy report on adult services has not yet concluded. Older teens and young adults cannot be passed direct to adult services until NHS England is certain that these services provide a normal standard of care, rather than an ideological, activist approach that would put these young people at risk.

Where is the outcome data for the approx. 2,000 children who went through the Tavistock GIDS? Without this data, it is unethical to continue to provide medical interventions in the dark.

Information about regret/detransition services should run alongside the gender service for those who discontinue medical treatment and need professional help to do this safely. The high drop-out rate in studies in this area suggests that the numbers who discontinue treatment may be significant.

The new service should be based on a diagnostic category of mental health; ‘gender incongruence’ is an umbrella term that spuriously links entirely disparate groups. The little boy who is most likely to turn out to be gay has no connection to the bullied, autistic teenage girl with body-hatred issues at puberty, who in turn has nothing in common with older autogynephilic adult males. Grouping them all together under a broad ‘trans’ label is illogical and misleading. Cass pointed out that some failings at the Tavistock GIDS stemmed from the prioritisation of ‘gender’ which covered up real problems. The ‘presenting problem’ that links these different cohorts should not be the foundational diagnostic framework of the service.

Children need protection from the propaganda and hard-sell of ‘gender identity’, which this generation has been uniquely subject to. Age protection must ensure that a foundational principle of the service is protection and safeguarding of children from ideas and medical practices that harm them (in terms of the blurring of boundaries between the sexes and confusion about reality, as well as the damage caused to children’s healthy bodies by medical interventions).

Adolescents are protected from permanent decisions, such as getting tattoos, for the reason that they are vulnerable to cultural/peer pressure before they have grown up enough to know their own minds fully or are able to weigh long-term consequences. Adolescence is an intense period of identity development and this generation, uniquely, is offered a pick’n’mix of ‘gender identities’ to choose from. It is concerning that NHS England is going along with an unprecedented cultural phenomenon, even to the extent that hormones are on offer for nonsense identities such as ‘non binary.’

Assessment must be sex-specific; a ‘gender neutral’ service will discriminate against girls by not taking into account the specific needs and vulnerabilities of girls at puberty compared to boys. Adolescent girls referred to the service must be viewed through a framework of female adolescent mental health. This is critical not least because it is the girls who progress to surgery at an earlier age and in greater numbers than boys.

NHS England must differentiate between different protected and at-risk groups and understand the specific vulnerabilities of each group. The Service Specification provides little reassurance that such distinctions are properly understood.

8. To what extent do you agree that the Equality and Health Inequalities Impact assessment reflects the potential impact on equalities or health inequalities which could arise because of the proposed changes?

Disagree

The Equality and Health Inequalities Impact assessment doesn’t reflect the realities of which groups are disproportionately disadvantaged/harmed by a medical pathway with no clear rationale or outcome measures, but serious and permanent effects.

Age

Age protections exist because children are still developing. Considerations for pre- and post-pubertal children are different, but they are equally serious. Younger children are vulnerable to influence by parents, family members and teachers. Adolescents are no less susceptible to wider cultural influences, including youth culture.

The EIA states that the purpose of the proposed service specification is to describe a delivery model that is ‘safe and evidenced based.’ The Cass Review revealed that the medical pathway is not adequately evidence-based and therefore cannot be claimed to be ‘safe.’ The duty to protect children is greater than with adults in terms of experimental medicalisation, and the least invasive treatment option must be prioritised.

Disability

Children with learning disabilities, looked-after children, those with associated severe mental health problems, including psychosis, drug addiction, self-harming, anxiety and depression, and autistic/ASD children are especially vulnerable to influence and exploitation. To diagnose these children with ‘gender incongruence’ (a diagnosis which doesn’t include symptoms of distress) does not address why these children are over-represented at gender services. As long as NHS England is confined by this one-size-fits-all diagnosis, these children’s specific problems and needs will be missed, and they will receive inadequate and potentially harmful healthcare.

Sexual Orientation

The EIA states ‘there is likely to be a lower percentage of children and young people who are referred to a gender incongruence service who identify / will identify as straight or heterosexual than for the general population.’ Again, without asking why, NHS England is minimising the risk to a protected characteristic group, which clearly demands greater understanding and knowledge before irreversible medicalisation is offered.  

Sex

The EIA sates ‘The proposals may disproportionately impact individuals who are natal female based on this data, but NHS England has concluded that no discrimination arises.’ As around 65% of referrals are now adolescent girls, and this is historically unprecedented, NHS England must investigate why so many more girls want to change their sex compared to boys.

Gender Reassignment

This protected characteristic does not fit with the majority of adolescents, who are not ‘transsexual persons’ as protected in this category, but troubled children who are picking a ‘gender identity’ they have learned they must choose as their ‘authentic self.’ The protected characteristic does not protect ‘gender identity’ or even mention this term. A protected characteristic which was originally intended to cover a distinct group of adult males wishing to ‘transition’ to the opposite sex, has no relevance to teenagers today who are picking a ‘gender identity’ off the shelf, which they have been led to believe is their true sex already.

Please submit your own response here. Deadline 11.59pm Sunday November 2nd.