The NHS interim service specification public consultation ends on December 4th and we urge everyone to send in a reponse. Overall we are very pleased to see that this proposed service specification for child and adolescent services is a move away from ideology and forward to a proper clinical care model.
Below is our full response to the public consultation. Please use this as a guide to submit your own response and add your own points, especially if you have experience as a service user or a parent (including your experience of trans policies in your child’s school).
3. To what extent do you agree with the four substantive changes to the service specification explained above?
A. Composition of the clinical team Agree
The team covers a comprehensive area of relevant disciplines. Expertise and knowledge is crucial in the following areas:
- Understanding of adolescent feelings of confusion and anxiety in the development/recognition of their sexual orientation and how this may relate to the over-representation of same-sex attracted young people (gay, lesbian and bisexual) referred to gender services, including the effects of homophobic bullying.1
- Knowledge of the difference between the watchful waiting and gender affirmative approaches and the statistics concerning outcomes of both approaches in terms of sexual orientation, mental health and resolution of gender dysphoria.
- Knowledge of the changed sex ratio in referrals to gender clinics, the change in age of onset of gender related distress from pre-pubertal to post-pubertal and the predomination and vast increase in the number of teenage girls experiencing a sudden onset of gender dysphoria during or after puberty.2
- An up-to-date knowledge of patterns in the development of mental health issues during adolescence and the differences between boys and girls, eg. differences in experience of the physical changes of puberty and how they might influence an adolescent’s self-perception, self-confidence and self-acceptance.
- Knowledge of the cultural factors affecting teenage girls and teenage boys differently, including social responses to pubertal changes eg. sexual harassment of girls, online influences eg. online porn, and social media pressures eg. ‘Instagram culture’ of idealised female sexuality and YouTube videos glamorising medical transition for teenage girls.
- Familiarity with studies of detransitioners and the reasons young people may regret medical transition.3, 4, 5, 6, 7, 8, 9, 10, 11
- Experience with family dysfunction and ability to recognise potential abuse, eg. munchausen by proxy or child sexual abuse.
- Expertise in female health issues specifically affecting girls, including mental health problems in adolescence such as body dysmorphia, anorexia, eating disorders and self-harm.
- Safeguarding and protection of children must be the first principle of care.
- A thorough knowledge of the Equality Act, the protected characteristics, Public Sector Equality Duty and legal obligations pertaining to equality law.
B. Clinical leadership Partially Agree
We agree in the sense that a medical doctor is more likely to follow the Hippocratic Oath ‘first, do no harm’, is less likely to be ideologically captured, and is comprehensively trained in diagnosis and treatment of the physical human body. Where any medical intervention may be proposed, a medical professional should be the clinical lead. It is important that the lead is not a ‘gender specialist’ who subscribes to ideological ‘gender identity’ beliefs, in denial of the material reality of sexed bodies.
However, the danger is that the service will be seen as a predominantly medical service, therefore it is especially important that the wider clinical team has expertise in a comprehensive area of disciplines.
C. Collaboration with referrers and local services Agree
Local services such as CAMHS have been undermined and therapists compromised by political pressures in this area, specifically by the risk of the charge of ‘conversion therapy’ if they provide standard levels of care to an adolescent who announces they are ‘transgender.’ If collaboration is going to be effective, the clinical team must provide reassurance to local services that a normal level of explorative therapy is expected, in line with all other child and adolescent services.
If NHS professionals are to be confident of providing a normal standard of care for gender dysphoric adolescents the NHS should remove itself as a signatory of the Memorandum of Understanding on Conversion Therapy as long as it includes ‘gender identity.’ Allowing for therapeutic exploration only in the case of service users who are ‘questioning their gender identity’ automatically excludes the majority of adolescents who are certain they are ‘transgender’, along with young children who have been told by trusted adults that they are ‘trans.’ Inclusion of ‘gender identity’ in the MOU has had a chilling effect on therapists, as evidenced in the Cass interim report, and is incompatible with the Cass report recommendations and this interim service specification. The most recent version of the MOU is an ideological campaign document controlled by activists12 and in order to support employees the NHS needs to show clearly that it is not an ideological body, but a health service.
The NHS must acknowledge the fear that has been created in this area and the highly charged political controversy, and must not be complicit in the silencing of clinical professionals. NHS England must show the way in not being cowed or diverted by political activists.
D. Referral sources Agree
Referrals should never have been accepted from social services, schools, colleges of further education or ‘voluntary organisations’ which included political lobby groups, none of which are qualified to refer children to GIDS and have typically been trained by ideological and political organisations.
4. To what extent do you agree that the interim service specification provides sufficient clarity about approaches towards social transition? Disagree
Whereas the interim service specification acknowledges that pre-pubertal gender incongruence rarely persists into adolescence, it does not specify that outcome research was conducted under a ‘watchful waiting’ approach (ie with no social transition). As the current cohort of largely adolescent referrals has been treated under a ‘gender affirmative’ approach, we have no idea whether gender incongruence/dysphoria would persist into adulthood for this cohort under a ‘watchful waiting’ approach. As this is a new phenomenon there is not yet outcome evidence for this group of adolescents and if there was it would be evidence of outcomes under a gender affirmative approach and therefore incomparable with earlier studies on younger children.
It is therefore imperative that the same level of caution around social transition should be applied to adolescents, especially in light of the fact that this age group has typically experienced online/peer pressure to identify themselves as ‘transgender’ and is of the age where medical intervention may be instigated.
It is this generation of teenage girls in particular who have been led to believe that medical transition will solve all their problems and have been coached online about what to say to the gender clinician in order to access hormones. No previous generation has been subject to such pressure to self-diagnose according to the beliefs of other people who are not clinically trained, and to believe there is one medical solution. This generation of adolescents believes they are literally the opposite sex to the same extent as pre-pubertal children do when they are affirmed and socially transitioned by adults.
The NHS should clearly distinguish between ‘affirmation’ as standard therapeutic practice (ie, a patient is ‘affirmed’ as how they present as a first step to exploring underlying meanings and understanding) and ‘affirmation’ as it is understood and promoted by gender activists (ie. a girl is ‘affirmed’ in her belief that she is really a boy or a boy is affirmed in his belief that he is a girl, as a fact which requires no further examination). The service specification should clarify that ‘gender affirmation’ is the first step to social transition.
We know from existing research that around 80% of pre-pubertal children desist from a cross-sex identity without affirmation and social transition, and become resolved and happy with their biological sex without having been harmed. The only research to draw on in the case of the current cohort of adolescents who have been affirmed and socially transitioned is the testimony of detransitioners, who desist after having been medically harmed by the NHS. This is reason enough to exercise the same level of caution about affirmation and social transition for the adolescent age group.
The results of a study this year 13 on outcomes for young children who were affirmed and socially transitioned shows the stark contrast with the approach of ‘watchful waiting.’ The study ‘Gender Identity 5 Years after Social Transition’ found that 94% of these children persisted in a cross-sex identity and 3.5% identified as ‘non-binary’, ie no sex at all or a mixture of both sexes. Only 2.5% desisted. The powerful influence on children of affirmation and social transition, informed by gender identity ideology, is clearly demonstrated in this study and it should not be assumed that this does not apply to teenagers. Such powerful psychological intervention cannot be dismissed as harmless and ‘reversible’ just because it is not medical transition. Rather, it should be seen as the first step on an almost-inevitable medical pathway.
The service specification should define clearly what ‘social transition’ means. It may sound benign, but in reality it means telling a child that they are really the opposite sex. The NHS cannot collude in telling lies to children about the fundamental reality of their sex, which cannot be changed. The NHS also cannot be party to the deception of children that medical intervention can change their sex. NHS paediatric services must be based on biological reality and must not seek to mislead children or encourage them to dismiss material reality and replace it with magical thinking.
Social transition is fundamentally incompatible with exploratory therapeutic support for children and adolescents experiencing distress. The NHS must not engage in psychological propaganda and indoctrination of children into a belief system with no basis in reality. The NHS is not a political lobby group and should not operate according to ideological concepts promoted by such groups.
To socially transition a child is to impose an adult belief on them and cement the child’s belief that it is reality, with no consideration of the psychological consequences to the child. It would be a dereliction of duty of the NHS not to make this clear to parents. Any adult in a position of authority over a child has a duty to be truthful about reality. Acceptance of reality is a foundation of good mental health; the role of the NHS is to help a child manage a reality which may be painful to them, not to pretend that that reality does not exist.
The NHS must also consider that ‘social transition’ is a demand on other people to collude in the pretence that a girl is a boy, or a boy is a girl. This is an infringement of other people’s rights to freedom of belief and expression with a particularly harmful effect on children in schools. If a school looks to the NHS for guidance in this area, information must be very clear. The psychological impact of being coerced to deny a fundamental reality is already evident in the confusion and distress expressed by some children in schools; the long term psychological impact on this generation is as yet unknown.
The NHS is a health service. Fostering a mind-body split in children through ‘social transition’ is the antithesis of good mental health practice. The consequences for the NHS in the future are not yet known but must be considered in light of the increasing number of young people who regret medical intervention, the effects of which they must live with for the rest of their lives.
The service specification states “Young people and their families will be supported in making difficult decisions regarding the expression of a gender role that is consistent with their gender identity, including the timing of changes to gender role and possible social transition” (p.15) without explaining what a ‘gender role’ is and how it is different for girls or boys.
This idea can only be based on stereotypes, for example a girl’s role is to be passive and nurturing, a boy’s role is to be active and competitive. It feeds into what may be the beliefs of conservative parents with rigid ideas about how their son or daughter should act and behave, and should not be reinforced by the NHS.
The service specification should make clear that freedom of expression is encouraged without tying certain behaviour, interests or appearance to one sex or the other. Social roles should be open to both sexes equally and the NHS should not be promoting or encouraging sexist ideas about what is appropriate behaviour for girls or for boys.
The only other way a boy, for example, can change ‘social role’ is by using the girls’ toilets and changing rooms and participating in girls’ sports, all of which are separated by sex, not gender. This would not only infringe on girls’ rights to separate facilities and sports, creating a safeguarding risk, it also makes clear that ‘social transition’ in effect means changing sex. A child should not be encouraged to believe they are of the opposite sex and other children (in a school for example) cannot be expected to collude in this belief.
The NHS should be clear about what message ‘affirmation’ sends to a teenage girl who hates her body and rejects her female self. To tell her that she is correct in her belief about herself, to confirm her self-hatred and self-rejection as valid is unprecedented as a treatment by the health service. ‘I’m transgender’ stated by an adolescent translates as ‘I hate my body and I hate myself.’ Affirmation and social transition is an approach that confirms she is right to feel this way.
The clinical team must include psychologists and psychiatrists who understand the full implications of affirmation and social transition on the minds of young children14 and adolescents.15
5. To what extent do you agree with the approach to the management of patients accessing prescriptions from un-regulated sources? Agree
Access to hormones from unregulated providers online is a growing problem, exacerbated by online and lobby group influence on adolescents to believe they need medical intervention immediately or they will regret it later. The NHS must not support the use of unregulated groups in any way and it is right that children and their families are strongly discouraged from using such services. The NHS is right to refuse clinical responsibility for management of endocrine interventions accessed through unregulated services. To collude would be to undermine the credibility of the NHS, by supporting a practice that puts young people at risk.
6. Are there any other changes or additions to the interim service specification that should be considered in order to support Phase 1 services to effectively deliver this service? (comments)
The statement “being mindful that this may be a transient phase, particularly for prepubertal children” (p. 2) should be amended to align with the information (p. 13): “in most prepubertal children, gender incongruence does not persist into adolescence.”
The wording should be changed, for accuracy, to “this is most likely to be a transient phase for prepubertal children and that there is no evidence to suggest that this would be any different for adolescents who develop gender dysphoria during or after puberty.”
The service specification states: “the main objective is to alleviate distress associated with gender dysphoria and promote the individual’s global functioning and wellbeing” (p. 2). These are psychological/mental health objectives and the NHS needs to make clear that cosmetic medical alteration of the body is not evidenced as a treatment for psychological problems.
The NHS needs to do more in education of parents, schools and charities on the potential harms of affirmation and social transition for both young children and adolescents, and provide clear information that this is an experimental approach with no evidence to show that it is safe. It was developed by activists, not clinical professionals, and has replaced the ‘watchful waiting’ approach without any evidence to show that this established model of care was harmful.
The NHS should provide accurate information about the harms of breast binders for girls and not condone their use as part of ‘social transition.’
Parents and schools need to know that sudden onset of gender dysphoria in teenage girls during or after puberty is historically unprecedented; that this is a very recent phenomenon, about which we have virtually no research or evidence, as indicated in the Cass interim report.
The NHS should also add accurate information for parents to dispel the myth promoted by activists that a child is more likely to commit suicide if not ‘affirmed’ and supported to medically transition.
The NHS needs to make clear that gender non-conformity is normal and healthy, and should not be pathologized by labels such as ‘transgender’ and ‘non-binary’, terms inevitably based on gender stereotypes that have emerged through political activism based on an ideology of ‘gender identity.’ Parents and schools need accurate information: that there is no scientific basis for the concept of innate gender identity (for example ‘a girl’s brain in a boy’s body’) and that these are not clinical terms, nor a clinical diagnosis.
There is no mention of services for detransitioners or any support for those who regret medical transition in the service specification. This is an issue the NHS must address urgently, as currently there is no provision of services for this group.
The NHS must re-examine the current age cut-off for child and adolescent services, and the transfer to adult services which leaves a very vulnerable cohort of older teens and young adults without the same standard of care outlined in this service specification.
In the statement: “…service design and improvement is coproduced with experts by experience and promotes equality, diversity and inclusion” (p. 19) it is not clear who the ‘experts by experience’ are. The group should not be comprised only of people who call themselves ‘transgender’ or parent activists of ‘trans kids.’ A middle-aged male cross-dresser, for example, can have no experience of the issues teenage girls face. It is critical that the group does not comprise only those who believe in gender identity ideology, but also those who reject it, including parents, detransitioners and adults (including gay and lesbian adults) who outgrew childhood and adolescent feelings of discomfort and distress about their sex.
The term ‘equality, diversity and inclusion’ likewise must include people with different beliefs. ‘Inclusive’ policies based on ‘gender identity’ (not a protected characteristic) can lead to exclusion of girls and women based on ‘sex’ (a protected characteristic). ‘Inclusion’ can lead to inequality as well as being a safeguarding risk for girls in facilities where they need privacy from the opposite sex, and the NHS needs to be especially aware of this in a service catering mainly to vulnerable teenage girls, some of whom will have been sexually abused.
In the phrase “Understanding of the differences in sexual identity and gender identity, and expression” (p. 24) ‘sexual identity’ should be changed to ‘sexual orientation.’ Sexual orientation is a fact, not an ‘identity’ and wording it this way conflates two very different things.
In the statement “Understanding of the role of education services in supporting children and young people with gender incongruence (supporting full access to the curriculum and pastoral support including, vulnerable children policies; toilet and changing room policies; pupils with special education needs and, addressing, exclusion, bullying and harassment)” (p. 25) the NHS should not be advising schools to allow boys who ‘identify’ as girls to use girls’ toilets and changing-rooms.
‘Exclusion’ based on sex is lawful policy to protect the privacy, comfort and boundaries of both sexes, and the safety of girls. The NHS cannot propose policies that create a demeaning or degrading environment for girls in schools. When the issue is the safeguarding of children, ‘privacy, boundaries and consent’ are the key words which must be placed above ‘equality, diversity and inclusion’ when it comes to sex-segregated facilities.
The service specification must acknowledge that the most likely outcome for pre-pubertal children who have a cross-sex identity is same-sex sexual orientation in adulthood, and that the majority of adolescents referred to gender clinics are lesbian, gay or bisexual.16
7. To what extent do you agree that the Equality and Health Inequalities Impact Assessment reflects the potential impact on health inequalities which might arise as a result of the proposed changes? Partially Agree
The ‘gender affirmative’ model, which did not meet normal standards of care in NHS child and adolescent services, resulted in indirect discrimination against several groups:
Age: the gender affirmative model is not developmentally appropriate treatment for children who have not yet developed an understanding of reality v fantasy, and adolescents whose identity development is in flux and liable to change. A principle tenet of safeguarding is that developmentally inappropriate expectations should not be imposed on children; this can be viewed as a form of emotional abuse.
Sex, Sexual Orientation and Disability: teenage girls, same-sex attracted young people and neurodiverse children and children with mental health problems, including gender dysphoria, are disproportionately disadvantaged by an unsafe system as they are disproportionately represented at gender clinics, as are children from the care system.
However, the NHS misunderstands the protected characteristic ‘gender reassignment.’ Although at the time this was written (Equality Act 2010) it may not have been envisaged as applying to children, the protected characteristic does not depend on a medical diagnosis of gender dysphoria, or on having taken any steps to ‘transition.’ It applies to ‘transsexual persons’ which suggests adults, but there is no age restriction. This protected characteristic, however, does not mean that a protected person must be treated as the opposite sex, only that they must not be discriminated against on the basis of this characteristic.
Whereas the previous NHS service specification in 2016 treated children protected by this characteristic unfavourably in comparison with other children with psychological/mental health problems, the new interim service specification treats them equally with other groups of children accessing NHS services.
The interim service specification, in addressing previous failings in order to establish a normal standard of care in line with other paediatric services, ends the failure of safeguarding and protection of these vulnerable groups. All children of all protected characteristics will benefit from a proper service of care. Health inequalities previously existed between the cohort of children accessing gender clinics and children accessing all other NHS health services and this health inequality has been rectified by the new service specification.
The EIA however, fails to consider other protected characteristics in its inadequate advice about social transition. Equality Impact Assessments must be tied to, and made in relation to, all advice in the service specification. The social transition of a child in school introduces compelled speech and imposes on the rights to freedom of belief of all teachers and children attending the school, under the protected characteristic ‘religion and belief.’ If school policies are introduced such as mixed-sex toilets, changing-rooms and sport, this would impact the rights of girls under the protected characteristic ‘sex.’ Coerced use of ‘preferred pronouns’ would disproportionately impact neurodiverse or learning disabled children under the protected characteristic ‘disability.’ Social transition of gay and lesbian children, who are more typically likely to be gender non-conforming, could be seen as a version of gay conversion therapy and therefore unfavourable treatment of same-sex attracted children under the protected characteristic ‘sexual orientation.’
The NHS must consider the rights of all protected groups in all the recommendations in the service specification, and not create inequalities for other groups outside the clinic through its advice.