The NHS needs a fundamentally different model of care for children with gender dysphoria to meet their needs, says a senior doctor.
dr Hilary Cass, who is leading a comprehensive review of services in England, has released her interim report.
She does not yet make any recommendations on the use of hormone treatments.
dr Trying to reassure young people who may be anxious while waiting to access NHS gender support, Cass said the services would not be discontinued.
“I think more services are needed for you, closer to where you live,” she told them.
The review states that children and adolescents with gender-based distress “need to receive the same standards of clinical care, assessment and treatment as any other child or adolescent who receives access to health services,” and emphasizes that they must be able to access psychological to get support.
There is currently a single specialist clinic in England and Wales providing gender identity services to children and young people – the Gender Identity Development Service (Gids), based at the Tavistock Center in London.
In recent years, there has been a sharp increase in referrals to the clinic, and it has been difficult to keep up with demand.
The clinic was deemed “inadequate” by inspectors who visited it in late 2020 after concerns were raised by whistleblowers and reported by BBC Newsnight.
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Children and young people have now been waiting over two years to be seen without support, and Dr. Cass says this delay risks compounding her distress.
The Tavistock and Portman NHS Foundation Trust has announced that Dr. Cass and NHS England to work together to support their recommendations.
The report finds that many young people using the service have a range of mental health needs, children in care are overrepresented and about a third of those referred to Gids have autism or other neurodiversity.
It describes a problem it calls “diagnostic overshadowing,” where a child’s health issues that would normally be treated by local doctors can be overlooked after they are determined to have gender-related issues.
dr Supporting a plan to move from a specialty clinic to regional centers, building capacity and reducing wait times, Cass writes that the current provider model is “not a safe or viable long-term option.”
The review notes that within the current specialty service there has been “a lack of routine and consistent data collection” and its approach “has not been subject to some of the normal quality controls normally employed when new or innovative treatments are introduced”.
The review team say they are not yet able to advise on the use of physical treatments such as puberty blockers and hormones due to gaps in the evidence base, but are working to develop recommendations.
Puberty blockers – powerful drugs that block the action of sex hormones and have been used to delay puberty – were the focus of a 2020 court case in which judges initially ruled minors were unlikely to consent to the treatment. The decision was later overturned by the Court of Appeal.
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This case was brought up by Keira Bell, who said staff at the Tavistock should have challenged them more about the transition.
The report by dr. Cass also says the current system, in which Gids clinicians make a gender dysphoria diagnosis and then turn to endocrinologists to prescribe puberty blockers, should be changed, with prescribers becoming active partners in the decision-making process.
In the short term, the review group set up to investigate cases referred by Gids for hormone treatment should continue its work, says Dr. Cass.
Keira Bell spoke to the BBC’s Alison Holt in 2020 about her decision to switch and then go back to being a woman:
dr Cass says the largest group of patients now being referred to Gids are teenage, registered women at birth who first developed gender distress in their early adolescence, while most of the research has been done on young people who are Men were born and felt unwell An early age.
Because this change in case mix dates from only 2014-2015, the review says it is too early to assess the longer-term outcomes for this cohort, “since young people may not achieve fixed gender expression until their mid-20s.”
In a letter to children and young people at the beginning of her report, Dr. Cass that many doctors still don’t know about the long-term effects of hormone treatments.
“What we’re going to do over the next few months is try to understand all the information that’s available and see if we can fill any of the gaps in the research,” she writes.
Elsewhere in Europe, Sweden last month announced new protocols that avoid the use of hormone treatments for most under-18s amid concerns about their risks and a lack of evidence.
The Tavistock and Portman NHS Foundation Trust said in a statement it welcomed the review’s focus on improving and expanding the care and support available to this patient population and on developing the evidence base.
“We will work with you [Dr Cass] and NHS England to endorse their recommendations.”
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