Tag Archives: Cass review

NHS public consultation on treatment of gender dysphoric children

The consultation ends on December 4th. I broadly welcome these proposals as a long over due return to holistic treatment of the child; rather than blanket ‘affirmation’ of a child’s expressed wish to ‘transition’. Whether you agree or not, please have your say. It is important that the consultation has a wide range of responses.

On 20th October 2022, NHS England opened a consultation to seek views on a proposed interim service specification for services for children and young people with gender dysphoria. Once agreed, this interim service specification will be operational only until a new service specification is formed in 2023/24 that will be used by a new configuration of regional providers.   The consultation closes on December 4th 2022 and NHS England recognises the importance of involving the public

…to check whether proposals are right and supported, whether the public understand their impact, and to identify any alternatives before decisions are made. 

This consultation follows the the Cass Review’s interim report, which was commissioned to investigate concerns over the significant surge in in the last few years in the number of children referred for medical treatment for ‘gender dysphoria’ – (the number of referrals is currently at 8.7 per 100,000 population per year in 2021/22 compared to 4 per 100,000 in 2020/21 and 4.5 per 100,000 in 2019/20) alongside the scanty evidence base to support claims about the efficacy of such interventions. The ‘single gender clinic model’ of the Tavistock GIDs had also proved an operational failure, with long waiting lists.

There is much to be very pleased about in terms of protecting children from significant medical interventions that currently lack any compelling evidence base. The key points set out below represent a very welcome and timely return to psychotherapy as the first and usually only treatment for gender dysphoric children; thus England joins Finland and Sweden in explicit rejection of the WPATH guidelines 

The consultation explicitly recognises that ‘gender incongruence’ may be a transient phase, particularly for prepubertal children, and that there will be a range of pathways to support these children and a range of outcomes.

The consultation examines 

  • How care is currently provided.
  • How the interim service specification could change care and the way that services are delivered, and the reasons for these changes.
  • How the proposed changes will be implemented.

The Good – Key Points 

  • Biological sex must be recorded and tracked
  • The importance of a DSM-5 diagnosis of ‘gender dysphoria’ as a gateway to treatment – which is characterized by significant distress and/or functional impairments related to “gender incongruence”. This is in contrast to the reliance by WPATH SOC8 on the ICD-11 diagnosis of “gender incongruence,” which is not necessarily associated with distress and relies primarily on the individual’s own subjective desires for certain treatments.
  • Thus the ‘gender affirming approach’ which originated in the USA has been abandoned and the focus returned to psychoeducation and psychotherapy, rather than an assumption that such children should automatically receive speciality ‘transgender health care’. 
  • Treatment pathway will thus be devised by examining the “clarity, persistence and consistency of gender incongruence, the presence and impact of other clinical needs, and family and social context.”
  • Decisions about a child’s eligibility for medical treatment will be made by a centralised service and puberty blockers will be prescribed only in ‘research protocol settings’ . Cross sex hormones are not mentioned, but it is assumed that a similar approach will be taken here. Those who attempt to access medical intervention outside the NHS protocol will not be supported by the NHS – which may initiate child safeguarding referrals. 
  • All children and young people being considered for hormone treatment will be prospectively enrolled into a research study which will track them into adulthood and provide a secure evidence base about the effects of hormonal interventions
  • ‘Social transition’ is recognised as not a neutral act – it may have significant effects on psychological functioning and is to be discouraged. It should only be pursued in order to alleviate clinically significant distress or impairment in social functioning and only after an ‘explicit informed consent process’. 
  • Emphasis on a multidisciplinary team that goes beyond “gender dysphoria specialists,” to include experts in other relevant areas such as paediatrics, autism etc to enable holistic support for gender dysphoric children. 

The Bad – captured language and magical thinking 

Some have raised serious concerns about some of the language used in the consultation documents. As Isla Mac commented (see further reading below), service specifications are provided in ‘captured language’ based on ‘magical thinking’ which is ‘meaningless nonsense’ and is likely to impede the necessary interventions of the multidisciplinary teams. 

I do not share the same degree of concern raised by Mac and could find only one reference to ‘sex assigned at birth’ against another reference to ‘birth registered sex’. 

What does trouble me however is that the term ‘gender identity’ is embedded in the consulation at numerous points – I have not noted any attempt to define what this means and to what extent it differs from simple reliance on sex-based stereotypes. For example in the ‘background section’ it says 

A quick look at the term used to describe a discrepancy between birth-assigned sex and gender identity is ‘gender incongruence’.

Conclusions

However, I balance my concern over use of the term ‘gender identity’ or ‘sex assigned at birth’ against the very welcome rejection of the WPATH guidelines. We now have a long over due return to an approach that sees the whole child in the context of their family and their environment, rather than simply affirming a ‘trans child’ to be hurried through to medical transition. 

I will therefore be responding to the consultation to say I broadly agree with it. Whether you also agree or you don’t, it is important that the consultation hears from as many people as possible. Please have your say. 

Further reading 

The Cass Review’s interim report

Society for Evidence Based Gender Medicine wrote about the proposals on October 24th 

Isla Mac raised her concerns about the language in the report, noting that magical thinking would not assist children facing mental health challenges.