Consultation on new youth gender clinics

We agree with holistic assessment and formulation but have concerns about how they are framed as “helpful in identifying other factors that may be influencing gender-related distress…”
This implies factors identified in assessment e.g. adverse childhood events, mental health problems, same sex attraction or autism are “other factors” influencing gender related distress rather than potentially causative, implying that once dealt with a distinct diagnosis of “gender incongruence” can be distilled. (The Cass section about this is illustrated by a drop emerging from a filter).
This suggests formulation is little more than a process to assist differential diagnosis, undermining its value as a way to consider all factors predisposing to, precipitating or maintaining the child’s gender related distress, and indicating potential therapeutic interventions. The description of differential diagnosis as a process for “determining the most likely cause of symptoms” by “ruling out other possible diagnoses that present in a similar way” to arrive at a “formal diagnosis”, adds to this impression. It is inconsistent with assessment and formulation as open to different possibilities about causes of distress and potential therapeutic approaches. The formal diagnoses listed as potential outcomes of formulation are ICD11 “gender incongruence” or DSM5 “gender dysphoria”. There are significant problems with these diagnoses.
Both diagnoses lack validity and predictive power. ICD11 “gender incongruence” provides no rationale for clinical intervention. It is based on gender non-conformity and is defined as a non-pathology specifically excluding distress. “Gender dysphoria” is not a diagnosis but a distress symptom, requiring exploration and, if appropriate, psychotherapeutic intervention. Both rely on regressive gender stereotypes.

Assessment and formulation can lead to a holistic individual care plan without the Gender Incongruence diagnosis. It should be dropped.

The assessment section on education and social context should include the role of social media influencers and external agencies, often operating through schools, on CYP’s feelings about their gender and their bodies, contributing to the x30 increase in adolescents attending gender clinics. They have been powerful in persuading CYP one can be “born in the wrong body”, that it’s possible to change sex and the only solution to gender distress is hormone treatment, often presented as “lifesaving”. They fail to inform about risks or harms. Understanding how cultural ideas may have influenced CYP is crucial to understanding their gender related problems.
The assessment must be stronger on safeguarding. Clinicians who become aware hormones, anti-androgens etc. are being provided from unregulated sources should make a safeguarding referral.
It’s important that family assessment does not label families with concerns about their child’s transition wishes as “transphobic”, thereby contributing to family alienation.

We support the approach but believe it should be much clearer and stronger. The provision of puberty suppressing, gender affirming hormones or other drugs like anti-androgens from unregulated sources is a safeguarding issue. Any clinician who becomes aware this is happening should make a safeguarding referral.

However, we are concerned that the policy in the draft service specification is contradicted by policy in the Gender Affirming Hormone (GAH) clinical policy to which the service specification is linked. Appendix A of the GAH clinical policy says there are circumstances where the Service will continue prescribing hormones initiated outside of NHS protocols, directly contradicting the policy in the service specification. The service specification must clarify this and the contradictory advice allowing prescription of hormones initiated outside NHS protocols under some circumstances should be removed from the GAH clinical policy.  

We know from doctors and therapists who are seeing children with gender related issues that children as young as 14 are being prescribed anti-androgens such as cyproterone, dutasteride and spironolactone, as well as oestrogen and testosterone  by overseas online organisations such as Gender GP, and at least one GMC registered doctor in the UK. There may be others. The point is that the “rogue prescribing” of dangerous substances includes a far wider range of drugs than puberty blockers, oestrogen or testosterone, and NHS gender clinic doctors may become aware of this.

These are serious safeguarding issues. It is substance misuse by the child and child abuse by those who are supplying or facilitating this (including sometimes parents). All such cases should be referred to social services who should be empowered to investigate and act, supported by appropriate legislation. 

It is weak and buck passing for the service specification to say “warn patients and parents of the risks” and let the GP know. Of course the GP has a similar duty if he or she becomes aware that such drugs are being prescribed outside the law or outside NHS protocols, but it is the duty of any and every clinician who encounters a safeguarding issue to take action. The service specification should make it clear that if a clinician becomes aware these drugs are being obtained by a child outside NHS protocols they should refer to social services and if they find out they are being prescribed by a UK registered doctor they should refer to the GMC.

We agree with the proposal of a National Provider Network to ensure that there is a consistent approach to various elements of service delivery, research etc, but believe safeguards should be included to encourage and support critical thinking, questioning of assumptions and expression of different views within the team in order to prevent “group think” and the kind of errors that led to the GIDS debacle whereby clinicians felt unable to express concerns or criticisms and the leadership team were imbued with and committed to a particular ideological viewpoint. This led to unsafe practice that was unable to respond effectively to changes in the evidence base or concerns raised by patients, families or staff.

What safeguards are in place to ensure this doesn’t happen within the National Provider Network.

The service specification says that one role of the National Provider Network is to work with NIHR and the National Research Oversight Board for Children and Young People’s Gender Services to contribute to study and treatment evaluation priorities including building further evidence on the safety, potential benefits and harms of both medical and non-medical interventions.

While these aims are laudable, we are concerned that the following research aims that were in the March draft have been removed from the August draft:

“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 have such important issues been removed from the explicit list of research priorities? We have little understanding of the fundamentals such as aetiology, epidemiology, natural history or predictive power of the various diagnoses used. The service spec shows the graph of rapid 30x increase in referrals with disproportionate numbers of teenage girls, yet the proposal to research epidemiology is omitted.

Recall that Cass said we don’t actually know anything about this cohort. Yet it is proposed that a national programme to “treat” these young girls be rolled out, with irreversible hormones being one of the options, without doing basic research first to understand the cause of the phenomenon.

It is extraordinary that this essential and fundamental research is being deprioritised. The National Provider Network has a duty to promote research that will enable a safe and effective treatment programme to be developed.

The service spec says the National MDT will consider recommendations for assessment of suitability for exogenous hormones as described in the clinical commissioning policy but that policy is out-of-date, non-evidence based and not Cass aligned. The MDT should not be using the Gender Affirming Hormones policy to guide its recommendations for suitability for exogenous hormones. It is unsafe and should be rescinded.

It is proposed that the Service collect data on the “needs and experience” of patients referred to the Service. While that is clearly important we question why the following proposal about data collection in the March draft was removed from the August draft?

“Audit and evaluation

As part of the National Provider Network the Service will take part in continuous data collection, reporting and audit to support the NHS in developing a better understanding of the relevant patient cohorts; 

It is important that the opportunity is taken to gather further evidence on the safety, potential benefits and harms of medical interventions.”

It seems the role of data collection has been much reduced in the current draft service specification. In order to be Cass aligned the wider goals of data collection that were in the March 2025 draft service specification should be reinstated.

The current version does not mention that data collection could be used to support the NHS in developing a better understanding of the relevant patient cohorts. Isn’t that exactly what the Cass Review said was needed? 

“Throughout the course of the Review, it has been evident that there has been a failure to reliably collect even the most basic data and information in a consistent and comprehensive manner; data have often not been shared, or have been unavailable. This has led to challenges in understanding the patient cohort, referral data and outcomes, all of which have hindered the work of the Review.” (Cass 18.52)

And shouldn’t data be collected to gain further evidence on safety, benefits and harms of medical interventions?

Cass said: “there remains the need for the collection of an agreed core dataset to inform service improvement and research…. This will be critical to informing current and future clinical practice and care for this population.(Cass 18.58)

We think the proposal that the data set “will be collected for all patients referred into the Service, including those for whom, following assessment, it is determined there would not be benefit from intervention by the Service,” is important as it will enable better understanding of the whole cohort.

The draft service specification outlines the role of the Children and Young People’s Gender Service in leading a network of Designated Local Specialist Services and states that this is to align the specification with the final report of the Cass Review which recommends that NHS England and service providers should establish regional networks of local services that include primary care, mental health services and paediatric services and says the changes will support greater integration of the specialist gender services with other local services to support all of a child or young person’s clinical needs.

While this model sounds sensible in principle, in practice it is going to run up against serious difficulties unless something is done to tackle the lack of provision and long waiting times for Child and Adolescent Mental Health Services and ASD and ADHD services, as well as the lack of support for primary care in taking on the role allocated to it. All components of a network of local services must be strong and well supported for this plan to be effective.

Waiting times for CAMHS vary around the country but can be 1-2 years, with many children and young people not meeting the referral threshold. Similar long waits exist for ASD and ADHD services. The Cass Review said it was important to improve access to mental health services for CYP generally and not just for gender issues.

It is not clear what the role of paediatric services will be in this network. General paediatrics has no obvious role in paediatric gender care. Is the service specification referring to community paediatric services? Are they adequately supported to provide this extra level of service?

The service specification lists primary care as part of the network of local services but there is no information or support being provided for general practice in the role that is envisaged for it in this service. Although GPs cannot refer directly the Cass Review made it clear that GPs would have a role in making an initial assessment and deciding whether or not to refer a child or young person for gender related issues to mental health or paediatrics. 

The basis on which a GP would make such an assessment and decision is not explained anywhere – not in the Cass Review, not in the RCGP transgender healthcare policy and not in the draft service specification. This is not trivial as Cass envisaged that the GP role would reduce referrals and “have an immediate effect on reducing the length of time children and young people are waiting to be seen…”

This is a big responsibility, and it is surprising it is not being addressed anywhere. Furthermore, there is little to no information about what support GPs could provide for CYP that they decided not to refer, or while the CYP they do refer are waiting for their appointment with CAMHS or paediatrics.

The service specification has a referral pathway for exogenous cross-sex “gender affirming” hormones and says the role of the National MDT in considering recommendations for exogenous hormones is described in the gender affirming hormone (GAH) clinical commissioning policy. That policy is out of date and unfit for purpose. It was published 3 weeks before the Cass Review and is uninformed by the evidence or recommendations in the Cass Review, or any other evidence.
Cass Recommendation 8 said “There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18.”
The GAH policy contains no clinical rationale for hormones for 16–18-year-olds. It claims to have reviewed the clinical condition and evidence of risks and benefits of exogenous hormones. There was no evidence review or risk/benefit analysis.
The Cass Review raised concerns about lack of evidence for hormonal interventions, especially for the new cohort of teenage girls and recommended if GAH were prescribed, it should be with extreme caution. The GAH policy contains no guidance for the MDT on “extreme caution”.
The GAH policy ignores systematic evidence reviews of GAH, such as NICE (2020) which showed only very low or low certainty evidence of risks and benefits, and ignores significant safety concerns.

The GAH eligibility and readiness criteria are derived from the 2017 Endocrine Society guidelines which are themselves based on the 2012 WPATH guidelines. They provide no rationale for use of cross sex hormones in 16–18-year-olds including no evidence or risk/benefit analysis.

The GAH policy bases eligibility on a diagnosis of gender incongruence but the Cass Review states that diagnoses of gender incongruence or gender dysphoria have poor predictive power (Cass 16.8) about who might persist with a transgender identity into adulthood, or benefit from medical transition. This applies even more to the new cohort of female adolescents with gender dysphoria/incongruence, the natural history of which is unknown. (16.21). There is no evidence that “clarity, persistence or consistency of gender incongruence” enhances predictability and should not be the basis for MDT hormone decisions.

Cass also warns about risk of irreversible treatments for a condition which may be psychosocial or sociocultural in origin (16.9), lack of knowledge of risks, benefits and long-term outcomes making it difficult to obtain informed consent. (16.34) and asks whether it might be better to delay consideration of hormones until age 18 to keep options open and allow time for management of other issues. (16.39). (all references Chapter 16 Cass Review)

Consequently, the service specification should remove the endocrine pathway just as it removed the puberty blocker pathway “because of the limited evidence about safety, risks, benefits and outcomes.” Without a sound evidence base, there should be no role for the MDT in prescribing exogenous hormones.

The proposal for a separate pathway for pre-pubertal children came from recommendation 4 of the Cass Review.

Cass made this recommendation because most children seen at GIDS clinic had already fully socially transitioned. She was concerned social transition “may have significant effects on the child or young person in terms of their psychological functioning and longer-term outcomes” and “may change the trajectory of gender identity development for children with early gender incongruence.”

Therefore Cass recommended early discussion with clinicians who should advise a more cautious approach for pre-pubertal children, such as “partial transition”, making it easier for children to change their gender presentation later if they changed their minds.

We’re concerned the specification misrepresents social transition, failing to distinguish between it and gender non-conformity:

“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’.”

Actually, social transition is the presentation of the child as if they were the opposite sex.
It is important to distinguish between harmless gender nonconformity and the pretence that someone has changed sex. Many young children believe they have changed sex and some parents reinforce this. This is a false belief and has potential for harm.

These concerns were expressed by the Multi Professional Review Group who reviewed all referals for puberty blockers:
“The MPRG is concerned that some children are continuing to live in stealth, with a common, genuine fear of ‘being found out’… MPRG observe that living in stealth appears to increase a child’s level of stress and anxiety with resultant behaviour and mental health problems, including social withdrawal, with children becoming increasingly isolated, including resorting to home- schooling or tutoring, with some distressing descriptions of children rarely leaving their house”. (MPRG report in Cass Review)

The MPRG noted: “Most children and parents felt isolated and desperate for support and have turned for information to the media and online resources, with many accessing LGBTQ+ and GD support groups or private providers which appear to be mainly affirmative in nature and children and families have moved forward with social transition. “

We agree early discussion with clinicians would be helpful for children and parents before making hard to reverse decisions but are concerned some clinicians in the new service may share the approach of some former GIDS clinicians and take an overly “affirmative” approach, promoting full social transition. This risks the separate pathway for pre-pubertal children becoming a fast track for pre-pubertal children into medical transition. It’s vital clinicians have appropriate training on social transition to prevent this, as it would defeat the purpose of the separate pathway.

The draft service specification says “There are currently no outcome measures for this Service.”

If there are no outcome measures that means you don’t know the purpose of the service. How then can you have metrics to monitor and assess the quality of the service?

The service specification says: “However, a range of quality metrics have been developed which, through regular data collections, will support an enhanced understanding to the quality of the service delivered (see Appendix C). As relevant outcome/impact measures are developed the service specification will be updated.”

This is like trying to build an aeroplane while you are flying it.

All the metrics are process metrics except for one outcome metric which is: “Proportion of children and young people with improved Children’s Global Assessment Scale (CGAS) on discharge compared to baseline (during initial assessment appointment by the service)”

The Children’s Global Assessment Scale (CGAS), adapted from the Global Assessment Scale for adults, is a rating of general functioning for children and young people aged 4-16 years old.

According to the Child Outcomes Research Consortium (an Anna Freud Project) “no study has been published regarding the suitability of the measure for children and young people in the UK and across different ethnic or linguistic groups.”

This means that the only outcome metric being proposed is a general one and not specific to the gender service and not validated for the children who will be seen in the service. All the other metrics are about processes, but they tell you nothing about the quality of the service in terms of its intended purpose. In theory you could have good process metrics for a service that was not achieving anything or even doing harm.  

We propose that the Service first of all decides its purpose and desired outcomes and then develops quality metrics to assess progress towards these outcomes. Process metrics should be secondary to this.

The service spec says it is for CYP with WHO ICD11 diagnosis “Gender Incongruence” (GI).

Using “Gender Incongruence”, an avowedly “non-pathologising” diagnosis, does not make sense. If it is not a pathology why does it need treatment? If the purpose of removing gender incongruence from the mental health category was to “depathologise” it, why not remove it altogether, as was done when homosexuality was depathologised? By retaining it in a disease classification system it is still a “pathology”, regardless of where it is located. In effect it pathologises gender non-conformity.

Its full title is “Gender Incongruence in Adolescents and Adults”, a “one size fits all” diagnosis that ignores the difference between adolescents and adults, whereby we understand adolescence as a time of intense identity exploration, fluidity and change. It is unlikely that what causes middle aged men to want to transition applies to teenage girls.

GI explicitly excludes “distress” or mental health problems. This leads the service specification to tie itself in knots to justify treating a non-pathology, repeatedly slipping back into talking about “dysphoria” and distress. Distress is mentioned 13 times in the service spec as relevant to clinical decisions, and the referral pathway mentions distress as a referral requirement by CAMHS, Paediatrics and, indirectly, by General Practice.
If the aim is to treat distress, why not use a mental health formulation? This would make sense as the primary intervention proposed by the proposed Service is psychological. Acknowledging that gender related distress is a problem of the mind not the body would enable the Service to provide a safe, rational approach to helping these distressed CYP.
According to WHO the reason GI was retained in the ICD classification was to enable funding and insurance for medical transition. The eligibility criteria in the GAH clinical policy state a diagnosis of GI is required for exogenous hormones, following the WHO line of using the diagnosis to justify medical treatment. But there is no rationale or evidence to support treating GI i.e. gender non-conformity (without distress) with irreversible and potentially harmful drugs.
The ICD11 GI diagnosis should be dropped. It has no utility: no prognostic value for persistence of a transgender identity and no criteria for deciding who might benefit from intervention.
It is based on gender non-conformity and desire for medical transition. “Desire”, without evidence of benefit, or concern about risk, is an irrational basis for NHS treatment.
Instead, the service spec should rely on formulation to elucidate the factors underlying a CYP’s gender distress, in all their complexity, pointing to the best ways to help.

The service spec should indicate intention to create a 17-25 follow through service without further delay, (Cass rec. 23). This should be a priority given the increased clinical risk of transferring to adult services at this vulnerable time.

The EHIA says in relation to Age:

“There are positive impacts to individuals who share this protected characteristic. The purpose of the proposed service specification for children and young people with gender incongruence is to describe a delivery model that is safe, evidenced based, (our emphasis) and that is focused on addressing a child / young person’s overall health needs in an integrated way, in line with the findings and recommendations of the Cass Review.”

However the Cass Review made it clear there is no good evidence base for any of the proposed treatments, whether medical or non-medical. We have outlined in another section why the Gender Affirming Hormone clinical policy that the service specification is linked to lacks any evidence base and is unfit for purpose.

The risk therefore is that children and young people under 18 will continue to be exposed to treatment pathways for which there is no good evidence and which may be harmful. This could include puberty blockers (if these are prescribed as part of research or following the research, or are ongoing prior prescriptions), and cross sex hormones. Cross sex hormones have a profound and irreversible effect on the body: in girls permanent voice lowering, beard and body hair growth, male pattern baldness, clitoral hypertrophy and genital atrophy and in boys irreversible breast enlargement and genital atrophy. There is evidence of long term metabolic and cardiovascular risks in both sexes, reducing life expectancy. Obviously the longer potentially harmful substances are used, and the younger they are started, the more harm could be done. Age is also a factor in considering whether a CYP can give informed consent about potential loss of or diminution of fertility and sexual function, or long-term health risk.

If the Service permits medical intervention without an evidence base for safety and efficacy, it risks harming young people.

The same concerns apply to the PCs of Sex, Sexual Orientation, and Disability. Girls, same sex attracted CYP (the EHIA minimises evidence for disproportionate referral of children with same sex attraction), and CYP with mental health issues or neurodiversity are disproportionately referred into the service and if the service is providing non-evidence based and potentially harmful treatments they will be disproportionately harmed. 

A non-evidence based and potentially harmful service could be detrimental to CYP with the PC of Gender Reassignment because it could potentially be providing “treatment’ that may not help them and may harm them.

We think that the risks of harms from the new service to CYP in relation to the PCs of age, sex, disability, sexual orientation and gender reassignment should be included in the EHIA.

(There is an error in the Equality and Health Inequalities Impact assessment where in the first section on Age it says the proposal for a pathway for pre-pubertal children is line with Recommendation 23 of the Cass Review. The proposal on a pre-pubertal pathway is actually Recommendation 4 of the Cass Review. Recommendation 23 is about a service for 17-25 year olds.)