Straight to the point

Since its closure was announced last July, Gids — the Gender Identity Development Service at the world-renowned Tavistock and Portman Trust — has become synonymous with mismanagement and medical scandal.

It was supposed to be a haven for young people experiencing gender-related distress. Instead, following a string of complaints by whistle-blowers, an “inadequate” rating by the Care Quality Commission, a high-profile judicial review and, finally, a damning independent review, it was deemed unsafe.

In its place, two new regional hubs were set to open, with several more centres to follow. For Gids’s long-standing critics, concerned about the distress its tumult was having on children, this came as a huge relief.

The story, however, does not end here.

Kathleen Stock has spent the past month speaking to a range of clinicians, NHS professionals and parents of dysphoric children — to find out whether Gids’s new service will be an improvement.

The portrait she paints is stark: her findings suggest that the NHS gender services are yet to become a clinically safe space for children and teens, with senior figures still pushing an activist ideology. Only last week, NHS bosses internally announced that they are significantly delaying the launch of one of the hubs. And as she reveals in the below investigation, it is unlikely to be the final twist in Gids’s new chapter…

Read on to learn about:

What happened to Gids?
The ideology in the new hubs
A new Wild West for patients

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In 2014, the head of the NHS Gender Identity Development Service, Dr Polly Carmichael, appeared on a BBC children’s television programme billed as the story of “an extraordinary boy… born with a girl’s body”. Soothingly addressing the tomboyish young protagonist sitting across from her, Carmichael was filmed saying that a “puberty blocker” — or to give it its proper name, a gonadotropin-releasing hormone (GnRH) analogue — “pauses the body and stops it from carrying on to grow up into a man or a woman”.

She continued: “The idea of the blocker is that if we can take away that worry about your body doing something that you don’t want it to, then it gives you and us more time and space to be really thinking about what’s going to be best for you now, but also in the future.” As she spoke, a cartoonish pause button symbol was projected onto the child sitting opposite her, whose moving image was then frozen to a still, to reinforce the point.

Back in 2014, Carmichael’s service — known as Gids, and based at the Tavistock and Portman NHS Foundation Trust in London, with a satellite clinic in Leeds — was still riding relatively high in public opinion. The clinical psychologist was often in the media, describing the challenges of treating a highly mysterious new being — the “transgender child” — to fascinated and relatively uncritical audiences. Indeed, the children’s television programme in question, My Life: I Am Leo, went on to win a Bafta.

But times change. These days — thanks to a string of whistleblowers, a high-profile judicial review involving a former patient, a rating of “inadequate” by the Care Quality Commission (CQC), and a cumulatively devastating book by investigative journalist Hannah Barnes — the name of Carmichael’s service is now synonymous with mismanagement and medical scandal. The closure of Gids was announced by NHS England in July last year, and an independent review is now well under way, also known as “the Cass Review” after its chair, the distinguished paediatrician Dr Hilary Cass.

Following Cass’s interim recommendations, published in February last year, two new regional services are being formed to treat “gender incongruence and gender-related distress” in children under 17, with several more centres planned for launch afterwards. Slated to open next month, the “Southern hub” involves teams from Great Ormond Street Hospital, the Evelina Children’s Hospital, and the South London and Maudsley NHS Foundation Trust. The “Northern hub” partners Alder Hey Children’s NHS Foundation Trust with the Royal Manchester Children’s Hospital.

Many long-standing critics of Gids have been reassured by these developments, and by the principled and cautious approach apparently taken by Cass so far. It seems she aims to examine trans-identification in children and adolescents systemically, applying what is known about wider paediatric health rather than sacralising her patients as exotic anomalies. One parent of a Gids patient, seeking anonymity for the sake of protecting the privacy of his child, as so many parents of trans-identified children do, told me with enthusiasm: “Gender has been exceptionalised as a clinical speciality, but Cass wants to weave it back into paediatric practice.”

But the story does not end there. Over the past month, I have spoken to a range of clinicians, other NHS professionals, and parents of dysphoric young people to understand how Cass’s guidance is being enacted on the ground. I have discovered that there are deep ideological tensions and conflicts within the very institutions — clinics, hospitals, trusts, commissioning boards, adjacent adult services — whose responsibility it is to implement Cass’s new vision. Moreover, it seems NHS systems are still influenced by activist thinking; in particular, by the idea that a sex-incongruent gender identity is something to be “affirmed”, either as a matter of social justice or as personal liberation.

Considered together, my findings suggest that the NHS gender services are yet to become a clinically safe space for children and teens. Last week, NHS bosses suddenly internally announced that they are significantly delaying the launch of the Southern hub — after months of preparing training materials for clinicians recruited into the new service, and only a few days before the materials were due to be used for the first time. In line with I Am Leo’s original metaphor, it seems that senior managers too are pressing the pause button, in order to have more time and space to think. In the meantime, thousands of distressed children and their worried parents wait anxiously for a resolution.

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What happened to Gids?

Despite the common belief that Gids closed following the announcement last year, it is still open, providing what it describes as “continuity of care” for around 1,000 existing young patients, including some on puberty blockers. (Cass recommended that in this interim period, any referrals to endocrine services by Gids staff should be reviewed by a multidisciplinary external panel).

It is unclear to outsiders exactly how patient care is now being managed at Gids, but what does seem true is that attempts have been made to improve existing processes since at least 2021. Published in February, an open letter from Gids staff concerned about Cass’s plans for the new services reveals that, after the CQC rating of “inadequate”, something called the “Gids Transformation Programme” was developed — separately from the Cass review, according to them — in order to make “wide-reaching changes to the running of the service”. The letter claims that external consultants were paid over £1.5 million to advise on the Transformation Programme, with some changes yet to be implemented.

At the heart of the controversy about the original service was its increasingly positive attitude to “gender affirmation”: roughly, the idea that a clinician should “believe” a girl who declares she is a boy (or vice versa), and so accede to her way of describing herself in clinical encounters. Though advocates deny it, critics insist that this practice precludes genuinely critical exploration of what may well be a passing phase. Without the capacity to gently challenge such a child in a therapeutic setting, an outcome involving lifelong medication is thought to become much more likely.

Even under the most scrupulous of arrangements, treating psychological distress in a physically healthy child or teen by administering experimental, powerful hormone-blockers carries risk. At Gids, that risk was increased severalfold by the organisational chaos of the service. During Keira Bell’s judicial review in 2020, High Court judges expressed surprise that clinicians did not seem to know how many young people had been referred there for blockers since 2011, nor of what age distribution. Only in 2022 — when Gids clinicians got round to publishing an analysis of outcomes for medicalised patients for the first time — was it announced that 1,151 children had been referred to the endocrine clinics in London and Leeds for puberty blockers and/or cross-sex hormones between 2008-21. According to Barnes, what proportion of them received puberty blockers still remains unknown.

 

There were other failures too, made clear in the course of Keira Bell’s judicial review and appeal, and in Barnes’s book. They include a startling absence of curiosity about certain recurring characteristics of patients — for instance, why so many of them were female, same-sex-attracted, and/or autistic. And there was also the close working relationship with the transactivist lobby groups Mermaids and Gendered Intelligence; inadequate preliminary assessments, both in quantity and quality; and a shocking lack of post-discharge follow ups.

In the past year or so, this impression of institutional disarray has been reinforced by Cass. In her interim report, she criticised management for having no standardised approach to patient assessment; no routine contact between psychologist and endocrinologist; no consistent safeguarding processes; poor record-keeping; and too-infrequent monitoring of medicated patients. She also seemed critical of affirmative approaches, noting with apparent disapproval: “From the point of entry to Gids there appears to be predominantly an affirmative, non-exploratory approach, often driven by child and parent expectations.”

In June, guided by Cass’s analysis, the NHS published an “Interim specialist service specification for children and young people with gender incongruence”, laying out the broad features of a new clinical pathway for this cohort — including standardised, genuinely exploratory assessment by multidisciplinary teams. Separate service specifications for puberty blockers and hormones are to follow. Cass has also insisted that, in future, puberty blockers should be administered in the NHS only as part of a properly managed clinical trial.

Despite the many criticisms of her management career to date, Carmichael remains in post as director of Gids. One of the main whistleblowers at the Tavistock, former staff governor Dr David Bell, told me: “Gids was found in the judicial review to be profoundly deficient in terms of clinical governance and record keeping. It is thus extraordinary that Polly Carmichael has been allowed to remain in position as director.” He described this as “a shocking message to parents and families who have been so damaged by this level of neglect”.

It is hard to find out which other clinicians still work at Gids, but many are assumed to be affirmative in their approach. In a second open letter from late last year — written from an affirmative perspective, in order to criticise the relatively positive response from the Association of Clinical Psychologists to the Cass Review — 13 signatories named their current workplace as Gids, including Carmichael herself.

One of the Gids-affiliated signatories was non-binary author and therapist Dr Jos Twist. Twist has edited an anthology, Non-Binary Lives: An Anthology of Intersecting Identities, which includes “stories of… how it feels to be non-binary and neurodiverse, the challenges of being a non-binary pregnant person, what it means to be non-binary within the Quaker community, the joy of reaching gender euphoria”. Another Gids signatory was clinical psychologist Dr Lorna Hobbs, who told The Guardian in January that, “for me, affirmative is starting from a stance that says gender diversity isn’t a disorder but has existed across cultures through history. It is saying ‘I believe you’ when you tell me about your experience.” Along with Twist, two other signatories who also claim to work at Gids — Dr Claudia Zitz and Dr Josh Goulding-Talbot — are now also listed as working at GenderPlus, a recently registered private provider with ambitions to prescribe hormones to teens (more on this below).

Such evidence suggests that the remaining patient cohort at Gids are not receiving the sort of care of which Hilary Cass would thoroughly approve. However, when it comes to the new services being built at the moment, it is not entirely clear that things will be much better…

***

The ideology in the new hubs:

Certainly, the presence of Professor Gary Butler in the new Southern hub does not instil great confidence that things have changed. For much of the service’s history, Butler was the endocrinology lead for Gids. In 2017, apparently with all the zeal of a true believer, he told The Daily Mail that, under his supervision, his clinic at University College London Hospitals NHS Foundation Trust “routinely” prescribed puberty blockers to children with “life-long” gender dysphoria: “When the team feels the young person is genuinely transgender they welcome [the use of] puberty-blocking drugs right from the early stages.”

Butler has also co-authored articles with Carmichael and others at the clinic. In one from 2018, he observes that “around 35% of referred young people [to the clinic] present with moderate to severe autistic traits” — apparently untroubled by the thought that he might be contributing to the premature sterilisation of autistic youth. For it is now recognised that, when combined with cross-sex hormones later, giving blockers to dysphoric young patients early on in puberty can inhibit the development of adult sexual function permanently — a fact occasionally openly mentioned by clinicians supportive of medical intervention but most of the time glossed over.

Yet Butler has now been recruited onto the team based at Great Ormond Street Hospital (GOSH) charged with developing training materials for clinicians in the new hubs. (Insiders I have spoken to believe that Polly Carmichael was initially on the recruitment panel, though the BBC reported that the decision to have her there was later “reversed”.)

Butler advertised his new role at a conference for gender medics in April, during a speech in which he also accused Cass of “nepotism” and said that the hospitals he was working with had no relevant experience with gender incongruence. He said he had “fought back” to “continue to be able to provide endocrine services for trans young people”. He has since rowed back on his comments and expressed support for Cass. But for David Bell, Butler’s presence in the new service still rings alarm bells: “Butler was responsible for being part of a service penetrated by trans ideology and neglecting the safeguarding of children; he is part of the Gids debacle and shouldn’t be involved in the new service.”

And Butler is not the only Gids clinician involved in the new hubs. I’m told that Dr Lorna Hobbs — the Gids psychologist who extolled the virtues of “believing” a trans-identified child to The Guardian in January — has advertised online that she is involved in the new service. Hobbs often reposts material from trans activist lobby groups on her public LinkedIn profile, and declares, on the website of a private therapy provider she also works for, that she applies a “social justice and equalities framework” to all the work she does.

One person working in the Southern hub told me that some clinicians recruited into the service “only believe in an innate notion of identity rather than one developing over time”. They added that involving such different voices on a single team was causing dysfunction. “The official position is that diversity of opinion in a team is a good thing, in order to mirror the fact that people don’t all agree in real life. But it doesn’t work. You can’t say yes and no at the same time.”

In the Northern hub, meanwhile, there is also a risk of repeating old mistakes. Buried within the July 2023 meeting minutes of the Alder Hey Board of Directors is the news that Leeds Children’s Hospital has now entered into the Northern hub partnership “as the existing providers of endocrinology services for children and young people under the care of the current Gender Identity Development Service”. In other words, endocrinology appointments for patients in the new service will apparently be managed by the very same hospital department involved with Gids Leeds, the satellite clinic of the Tavistock. On the current website for the hospital team, staff all list their pronouns.

Why were affirmative clinicians who were already tarnished by an association with Gids recruited into the new hubs, even after Cass’s recommendations? According to NHS sources close to both hubs, the most common explanation is cock-up rather than conspiracy. Managers at the relevant trusts don’t know much about the area, I was told, and when recruiting and setting up new structures, were likely to be impressed by a lot of mentions of “gender” on a CV. From this uninformed perspective, having already worked at the main NHS gender identity service for children presumably looks like an unimpeachable background.

Whatever the explanation, what does seem clear is that transactivist lobby groups and networks are strongly vocal in all of the trusts involved in the new hubs. Across the NHS, activist clinicians and support staff are pushing the idea that gender identity affirmation is a minority rights issue, and a way of furthering Equality, Diversity and Inclusion (EDI) goals. With “inclusive” policies about pronouns, changing rooms, and hospital wards already in place in a trust, the job of any clinician who wishes to resist affirmative narratives for dysphoric young people becomes that much harder. For fellow staff naively unaware of the potential clinical repercussions, it can easily seem that “respecting identities” is a simple matter of courtesy.

So, for instance, GOSH’s existing “Privacy and Dignity policy” instructs clinicians that “Trans and gender variant young people should be addressed and accommodated according to their self-defined gender or presentation e.g. the way they dress, and the name and pronouns that they currently use”. Guy’s and St Thomas’ NHS Foundation Trust’s trans policy says: “Asking and correctly using someone’s pronouns is one of the most basic ways to show your respect for their gender identity.” In other words — wider hospital policy in both trusts instructs clinicians and support staff to “affirm” any non-standard gender identity automatically, wherever it is encountered. It is unclear how such policies could possibly be maintained in the sort of genuinely exploratory clinical setting Cass apparently envisages.

Over at South London and Maudsley NHS Foundation Trust, meanwhile, all job adverts have Stonewall Diversity Champion branding. Freedom of Information requests also reveal that Mermaids provided EDI training to Childhood and Adolescent Mental Health Services (CAMHS) staff at the Maudsley Hospital last year. (The training this year was cancelled after adverse press attention.) Moreover, the hospital also has a vocal LGBTQ+ Staff Network, which seems to have some influence with management. I’ve been shown a copy of an email written by their leadership team in September this year, warning members of a visit to the Women’s Staff Network from Lynn Alderson, a lesbian feminist speaker with gender-critical and sex-realist views. After complaining that the speaker’s views were “divisive and hurtful, and in contradiction of our network’s gender identity statement”, the authors continue: “We have been assured that strict protocols have been put in place to prevent the speaker stating her views on gender, and that she will be ejected from the meeting if she does so.”

South London and Maudsley Trust also participates in the NHS Rainbow Badge scheme, described as “an assessment and accreditation model for NHS Trusts” and a “partnership between the LGBT Foundation, Stonewall, LGBT Consortium, Brighton & Hove LGBT Switchboard and GLADD”. (The Rainbow Badge scheme was actually founded by a medic working at the Evelina Children’s Hospital — the third hospital involved in the Southern hub partnership.) In a recent assessment, the Trust was given a Bronze Award, with particular commendation for its trans policies and for having “awareness posters across the site that reference microaggressions relating to homophobia, biphobia and transphobia” — though it was also marked down for a maternity policy that “uses gendered language throughout”.

A similarly ideological picture emerges in the North. Manchester University NHS Foundation Trust — which includes the Royal Manchester Children’s Hospital, one of the two children’s hospitals in the hub — also advertises its membership of the NHS Rainbow Badge Scheme, and in the recent past has used another scheme from the explicitly transactivist charity LGBT Foundation for training. The other one, Alder Hey Children’s Hospital Trust, is a member of the “Navajo Charter Mark” scheme — the North West’s equivalent of the Stonewall scheme, founded in 2010 to assess organisations in terms of “LGBTIQA+ friendliness” with a remit that includes “practices and policies” and “training”. Alder Hey was reportedly accredited by Navajo this month.

The content of Navajo training for organisations is unavailable to outsiders, but a 2019 Navajo newsletter perhaps gives us a sense of the organisation’s sympathies. It carries posts about banner-making workshops for Trans Pride, and regurgitates the persistent falsehood that “Almost half the trans kids of school age in the UK have attempted suicide”.

When it comes to implementing the recommendations of Cass, then, it is not inconceivable that local LGBT+ networks and transactivist groups within hospitals and trusts will put up resistance, whether active or passive. In April 2023, a NHS-sponsored analysis of responses to the public consultation on Cass’s interim service specification was published. Of the 411 clinicians who responded, 49% of them (the largest group) fell into “Group A”, described as “largely opposed to the proposals outlined in the interim service specification”, for reasons that included the perceived “transphobia” of some clinicians and the equation of “mental health treatments” for trans-identified youth with “conversion therapy”. Though obviously there was self-selection bias here, nonetheless the findings suggest there is a problem.

This sense is reinforced by the contents of a series of FOI requests made earlier this year to every NHS Trust in England and Wales that provides CAMHS, asking: “What if any training in gender, gender identity and equality your Clinical staff and practitioners have received in the last 4 years?” Some trusts replied that they paid explicitly trans activist organisations such as Mermaids and Gendered Intelligence to give them training; but even where trusts used less obviously partisan sources, it was clear from responses that the majority of them are employing a minority rights and inequality lens to look at gender identity, and not a psychological one.

And there is also evidence of at least partial capture in other powerful NHS bodies. NHS England was placed 68th in the Stonewall Top 100 Employers this year — an intensely fought competition with hundreds of entrants, in which a high placing indicates close policy compliance with Stonewall’s transactivist goals. The Care Quality Commission, in charge of regulation, proudly advertises on its website that it is a Stonewall Diversity Champion — as does the National Institute for Health and Care Excellence (Nice), Health Education England, and the NHS Confederation.

Elsewhere, the British Medical Association has come out in favour of affirmation, and published a response to Cass that criticises the new service specification for failing “to recognise the highly individual nature of children and young people’s experiences or their own developing autonomy in relation to exploring their identity”. The Chair of the Sexualities Section at the British Psychological Society, Dr Rob Agnew, frequently writes or endorses transactivist content on his public LinkedIn profile, including one post claiming that “[k]ids receive cis gender ‘grooming’ from the moment they are born” and that “[s]upposedly ‘experimental’ blockers are fully approved by the medical establishment and readily prescribed to cis kids for a variety of reasons”.

But this is not so. Some analyses suggest that blockers can negatively affect the bone density levels of young patients, and perhaps their renal and cognitive functions too. ​​A 2020 Nice evidence review — later acknowledged by Agnew after pushback — has concluded that the quality of evidence for the positive impact of blockers on “gender dysphoria, mental health and quality of life” is of “very low certainty”. There is also increasing doubt about whether blockers are beneficial or even just neutral for mental health.

Indeed, one NHS research trial manager I talked to expressed strong scepticism that a properly described clinical trial for puberty blockers — as mandated by Cass — could ever meet statutory regulations for what is known as “Good Clinical Practice”. She told me: “The Tavistock’s original application for their Early Intervention Study wasn’t regulated as a Clinical Trial of an Investigative Medical Product (CTIMP) but this one would have to be.” She added: “Children get classed as a vulnerable group. They need to have very special protections, and the rationale is just not there. The possible impacts [of blockers] on a child are so high that the moment that this was recognised, the study would be shut down. If you had a healthy child, and you recognised that medication could confirm sterility issues, or fertility issues, or bone density issues, the trial would be stopped at that point.” It would be “completely insane” to run such a trial, she concluded.

Meanwhile, even within the National Programme Board for Gender Services, the body ultimately in charge of service specifications for both adults and children with gender dysphoria, there are worrying signs for those seeking a clinical approach that situates dysphoria in the realm of paediatrics and psychology.

The Chair of the Board is Dr James Palmer, Medical Director for Specialised Services, a consultant neurosurgeon who has overseen all gender services in England and Wales in the past decade, both for children and adults. In 2018, he told a conference that the NHS needed to design “a healthcare service that will allow somewhere around 1-3% of the population at some point in their lives to have a discussion about their gender”. Talking about the drop in average age of Gids patients, he added: “It’s got to be a good thing that there are people out there that want to explore their gender. The fact that it’s in the younger age group has got to be a good thing. For a young adult, to be able to come forward, to seek that expertise, earlier [rather] than much much later in life, that’s got to be a good thing.” The lack of curiosity about why so many younger people were suddenly arriving in his services is marked. And in fact, there is evidence that early social and medical transition for a child experiencing gender dysphoria — carried out, of course, by adults — tends to solidify a sex-incongruent gender identity in the child that otherwise might well have passed.

Meanwhile, on the Clinical Reference Group for Adult Gender Dysphoria Services, described as providing “independent expert advice to the National Programme Board for Gender Dysphoria Services on the various aspects of the Board’s work”, two out of five of the members are openly affirmatory of children. Dr Laura Charlton, a clinical psychologist, works at Gids Leeds and was the first author of the open letter signed by Carmichael last year, defending affirmation. At one point, the letter complains of the use of “male” and “female” for trans-identified children because it “undermines the lived experiences of the people being referenced”.

The second affirming clinician on the board, Dr Christine Mimnagh, is clinical lead at the Merseyside adult gender service CMAGIC, and also a GP and private practitioner. In an interview last year, worth quoting at length, Mimnagh said about trans-identified children: “The first thing you get taught in safeguarding for children is, if a child comes up to you and says, you know… ‘I don’t like the way they touch me’, or whatever, what you do is go ‘OK, yeah, tell me more, I’m listening’… what you don’t do, is say, ‘Oh no they didn’t, that’s Mr Jones the gamesmaster, he would never do that!’ There’s a difference between affirmation and dismissal and with everyone whose trans, affirmation is kind of the name of the game; you can’t deny people’s reality just because their reality is different from yours.”

In other words: just as we should believe a child who says she or he is being sexually abused, we should also believe a female child who says she is a boy.

***

A new Wild West:

It appears, then, that despite the apparent good sense of Cass’s interventions so far, contemporary gender medicine in England and Wales remains somewhat chaotic. Within relevant services and wider NHS institutions, there are clinicians with directly clashing views about what sex-incongruent gender identity is, what it means, and what clinical decisions should be made as a result. And it seems that the cracks are starting to show.

I have seen evidence that, only last week, clinicians in the Southern hub — getting ready to launch in a month’s time, and to trial the new training materials with clinicians that very week — received a wholly unexpected internal announcement: the November launch had been postponed. Rising clinical, legal, and communication costs were cited, as was the insufficient time for senior clinicians to sign off the training materials in line with the proposed delivery schedule. I’m told that a manager of the team in charge of producing training materials resigned. Though teams within the Southern hub continue to be employed, their work is now paused, with no revised schedule yet in place.

What will this delay mean? With Gids closed to new referrals and the hubs not yet established, waiting lists will inevitably grow longer by the day. Now taken out of Gids’s hands and managed separately by a NHS Commissioning Support Unit, as of July 2023 7,902 children and young people were on the national waiting list. It is widely acknowledged that any child who is 16 is unlikely to be seen by a children’s service before she turns 17 (the cut-off point for care under childhood and adolescent services).

In desperation, some parents with enough means are turning to private providers to buy puberty blockers and hormones for their child. GenderGP is the most well-known of these, notorious for its close links with Mermaids — even to the extent of employing former CEO Susie Green for a few months this year — and for its historical run-ins with the General Medical Council.

But there are others who also see waiting lists as a business opportunity. The “Yorkshire Gender Endocrinology Services clinic” offers blockers on its website, though it’s unclear whether its clinicians would dispense these to under-17s. And last month, a new private clinic — GenderPlus — arrived on the scene, overseen by former Gids clinician Dr Aidan Kelly, with stated ambitions to start prescribing hormones to teens in the next couple of months. Several other former and current Gids clinicians are involved in this venture, most notably Paul Carruthers — lead nurse at the NHS Gids clinic still based at Leeds Children Hospital, and described as the person who will be “leading the hormone clinic” at GenderPlus.

For some parents, this is an attractive option. One told me: “I know there are parents who want to do it by the book and feel that GenderGP is not doing it properly. They want to go to a Harley Street clinic, get a diagnosis, and feel reassured by having a clinician registered with the NHS.”

Yet while GenderPlus is presented by Kelly as a new project, focused on hormones not blockers, it seems he might already have experience in prescribing blockers to children under the auspices of another of his businesses, Kelly Psychology. As an anonymous comment on the TransgenderUK Reddit put it a year or so ago: “There is another provider to GenderGP but it’s probably more expensive. I use Kelly Psychology and have a private endocrinologist who prescribes puberty blockers to my 13-year-old child. The process is the same as Gids but private.” (Kelly Psychology did not respond to a request for comment.)

Whatever the truth here, it is clear that Kelly is aiming GenderPlus at the parents of dysphoric children and adolescents, and that he anticipates big business. The company already lists 17 staff members on its website, including a research manager.

Given the acknowledged lack of a solid evidence base, to prescribe such poorly-understood drugs privately could be seen to be incautious. Cass’s new interim service specification is very explicit, with added red lettering for extra emphasis: “Children, young people and their families are strongly discouraged from sourcing puberty suppressing or gender affirming hormones from unregulated sources or from on-line providers that are not regulated by UK regulatory bodies.” Though GenderPlus has told The Times it is seeking registration with the Care Quality Commission regulator, its website currently says that it has “clarified” with the CQC that its service “does not fall under their remit and as such is not eligible for CQC registration. If in the future we do provide services which will require CQC registration then we will seek registration.”

Another major worry for many parents of children currently on the national children’s waiting list is the increasing proximity to adult services as their child gets older. In August this year, letters were sent directly to all 17-year-olds on the list, encouraging them to opt for referral onto the adult list instead. They were told that the original date on which they were placed on the children’s list could be transferred to the adult one, so that they could be seen more quickly. The letters were signed by James Palmer.

Since adult services tend to be uncritically affirmative, the letters have profoundly alarmed some parents desperately holding out for a non-medicalised resolution to their child’s dysphoria. In practice, it seems that a 17-year-old might self-refer to an adult clinic and be put on hormones on the day of her second appointment, without any psychological intervention; indeed, one clinic proudly advertises the possibility of prescription at this speed.

What makes this possible is the existing NHS adult service specification, written in 2019. It is a document that governs standards of care in all adult services, and is a world away from Cass’s careful formulations. Gender dysphoria, it states, is “not, in itself, a mental health condition” — making it somewhat obscure why the NHS should pay for treatment. Equally, “psychological interventions will not be offered routinely or considered mandatory”; and “the majority of individuals will have two core assessment consultations” (and no more). Individuals can also self-refer to a clinic without any intermediate referral from a GP. For breast removal, a patient will need the sign-off of one clinician within the service. For genital surgery, she will need two.

There are eight NHS gender clinics for adults in England and Wales, plus four new “pilot” services, brought in more recently to bring down adult waiting lists in local areas (one of these was mentioned earlier: C-Magic in Liverpool, run by Dr Christine Mimnagh — the clinician who made an equation between believing a child’s disclosure about sexual abuse, and affirming a child’s incongruent gender identity). The new pilot services tend to be embedded within sexual health services, are run by predominantly LGBTQ+ clinicians, and appear to be even more affirming than the already fairly ideological norm.

For instance, the website of Indigo, the pilot service in Manchester, says: “We know that trans and non-binary people are the experts of their own experience… Our services are trans and non-binary-led, with trans and non-binary people guiding and feeding into them at all levels.” An NHS commissioning document for the pilots says that Indigo is “testing the role of Care Navigators, a non-clinical role typically staffed by individuals with lived experience, to support patients before their first appointment with the specialist team”. Somewhat unusually for a primary care provider, Indigo also has a “Leave this site quickly” button on its website, taking browsers to Google if necessary.

I talked to Anna, the mother of a trans-identified daughter currently on the Gids waiting list who is nearly 17 and is seeking medical transition. Her daughter formerly identified as a lesbian. Over lockdown, she began to identify as a boy, having discovered transactivist websites. The teenager, who also has ADHD, is now living with an affirming father who supports her transition.

Anna told me: “I’m frightened that without any evidence of benefits, and with a high rate of neuroconditions and traits — bearing in mind that girls will be more undiagnosed than boys — without consideration for all of that, and with only one pathway in the adult services, our kids have no hope. I don’t want to say mutilated but that’s what is happening. There is so much regret, I don’t want our kids to have regret. They are only on one path, without any mental health considerations. I don’t understand how they can do it.” Along with another mother in a similar position, she is now seeking permission to pursue a judicial review against the NHS, “for providing unsafe treatment advice for young people from 17 years old and vulnerable adults”.

For David Bell, what is happening to dysphoric 17-year-olds is the “biggest area of concern”. He told me that, in light of their incomplete cognitive and emotional development, there is plenty of precedent already for 17-25 year olds to be treated separately from adults in mental health services; pointing me to guidelines from the Royal College of Psychiatrists and elsewhere in the NHS that have established this. He described the failure of adult gender services to recognise this as the “trans-exceptionalism” already familiar from elsewhere in the NHS. Indeed, with what another former Tavistock clinician described to me as a “beautiful irony”, the Tavistock and Portman Trust itself has an adolescent and young adult service in general mental health that covers 14-25 year olds — just not in Gids.

Cass’s interim service specification states that, when a child is moved to an adult service, “a co-ordinated transfer to appropriate local adult services will be needed where complex presentations continue”. It seems that, at the moment, such a rational arrangement is some distance away. In effect — thanks to the collapse of the old service and to delays within the new ones — a void has opened up in the systems supposed to care for gender dysphoric young people. And until it is filled, a cohort of highly distressed children and their desperate parents will continue to pay the price.

***

A spokesperson for the NHS Children’s and Young People’s Gender Service (London) said:

 “The NHS Children’s and Young People’s Gender Service for London — a partnership between Evelina London Children’s Hospital (part of Guy’s and St Thomas’ NHS Foundation Trust), Great Ormond Street Hospital and the South London and Maudsley NHS Foundation Trust — is working towards full mobilisation of the new service by the beginning of April 2024

“The set-up of this completely new service is complex. In advance of full mobilisation, we will be working with colleagues on the safe handover of current patients. We are also focused on recruitment, training and ensuring good data collection which supports the developing research, and progress made in these areas will determine how quickly it will be possible to start seeing new patients off the waiting list.”

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