Our submission to NHSE referral pathway consultation

referral pathway

Transgender Trend written submission to the NHS England consultation Referral pathway for specialist service for children and young people with gender incongruence.


Referrals must not be made by lobby groups, activist organisations, teachers, youth workers or other unqualified adults.

Somewhat agree

We agree that at age seven children are more developmentally equipped to engage with health professionals. But alongside this it is critical that NHS England develops evidence-based literature and website information strongly advising parents against ‘gender affirmation’ and social transition of young children, and provides training for all CYPMHS professionals and general practitioners in the developmentally-informed ‘watch and wait’ approach, in line with the MindEd modules.

Parents seeking advice must be able to access consistent information throughout all NHS England services. NHS England must put a stop to regional trusts displaying activist materials such as the ‘genderbread person’ in GP waiting rooms, or Pride displays in children’s hospitals. This is mixed-messaging that will confuse parents and children, putting young children at risk of developmentally- inappropriate and harmful psychological interventions by untrained adults.

Somewhat agree

However 17 year-olds must be offered support and mental health services through their local CYPMHS to address any co-occurring mental health issues, such as depression, anxiety, eating disorders or trauma, or issues relating to autism or sexual orientation, until such time as all CYPMHS professionals are upskilled in management of patients experiencing gender-related distress. This additional training must be a key priority, in line with training developed for the MindEd hub.


Older teenagers and young adults deserve the same normal standards of care as the younger cohort in the child and adolescent services. They should not be added to waiting lists for adult services until such time that these services undergo the same kind of review as the Cass Review of the child and adolescent service. The co-morbidities outlined by the Cass Interim report will not be addressed in the adult services, putting these children at risk of unnecessary medical intervention.

Adult services and NHS pilot clinics operate under the same highly inappropriate and irresponsible affirmation and informed consent model that was judged clinically unsafe for the child and adolescent service. The NICE systematic review of studies on cross-sex hormones concluded with exactly the same findings as the review for puberty blockers: the evidence for any benefit of this treatment is of very low certainty. Evidence for the safety of gender reassignment surgery has not yet been reviewed.

At adult clinics the diagnostic overshadowing highlighted by Cass is built into the service model. Older teenagers may be referred for hormones or even surgery without any exploration of underlying issues that may have led to the development of gender dysphoria. Children and vulnerable adults should not be put at risk of medicalisation with lifelong effects without proper exploration and diagnosis.

NHS England must develop a transitional young adult service for 17 – 25 year-olds, in line with normal mental health services. Sending a 17 year-old direct to adult services is wholly inappropriate. Until such time as transitional services are operational, young people must be able to access support through their local CYPMHS. It is critical that NHS England removes all training and advice developed in partnership with activist organisations, based on ideological concepts of ‘gender identity,’ and reverts to evidence-based practice throughout the service at every level.


This stage is critical. We would like clarification that the pre-referral consultation service is a pre-requisite for children currently on the waiting list, in order for a decision to be made about whether they will be added to the list for the new child and adolescent services or referred for other services, and whether this will start at the level of primary care.

As 17 year-olds currently on the waiting list were not referred through this more rigorous process, they must be re-considered for the pre-referral consultation service, not transferred to the adult clinic waiting list. This is a vulnerable cohort that has missed out on the differential diagnosis necessary before being approved for referral to a specified gender service.

GPs have previously been offered e-learning modules developed by an activist organisation, the Gender Identity Research and Education Society (GIRES) which was available on the RCGP website. We feel that primary care providers need re-training through the MindEd modules and that the description in 5.1 is an inadequate alternative to proper training.

5.1 is incomprehensible and includes ideological language such as a child’s strong desire “to be a different gender than the assigned sex” or “a marked and persistent incongruence between an individual´s experienced gender and the assigned sex.” There is no definition of subjective terms such as “experienced gender” and all this language should be changed simply to a child’s strong desire to be the opposite sex.

NHS England must leave schemes developed together with activist organisations, such as Pride in Practice and the Rainbow Badge scheme. These initiatives are ideologically-based and inconsistent with the evidence-based care developed for the new services. GPs should not be given mixed messages by NHS England and ideology must be taken out of all health services.    

The new service specification has rightly removed reference to conversion therapy. NHS England must now remove itself as a signatory to the Memorandum of Understanding on Conversion Therapy including ‘gender identity.’ MoU2 was an activist initiative now led by an unaccountable activist group. It is inconsistent with Cass findings, and inappropriate to frame therapy for gender-distressed children as a black and white political issue. It undermines therapists’ confidence in following the careful, nuanced process of differential diagnosis required by the new service specification.

Somewhat disagree

Health inequalities have been created for 17 year-olds currently on the waiting list who may be transferred to the waiting list for an adult clinic after consultation with their doctor, without going through the full pre-referral process. At the adult clinic they will not receive the same standard of evidence-based care as designed for the new child and adolescent service. This will disproportionately discriminate against teenage girls and those with co-morbidities, same-sex attracted youngsters, neurodivergent teenagers and those with the most complex needs such as looked-after children, who will not receive the careful differential diagnosis they need. 

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