A long-awaited review by pediatrician Hilary Cass of NHS children’s gender services is calling for a dramatic shift in the type of treatment offered to children and young people with gender dysphoria.
The report suggests that young people referred to NHS gender services, rather than mainly receiving medical treatment, should receive “a holistic assessment of their needs to develop an individualized care plan”, meaning that issues of gender identity should be addressed alongside other potential mental health issues. to assure.
It concluded that a medical pathway, such as puberty blockers, would not necessarily be the best option for children with gender dysphoria, and should not be offered “without also addressing wider mental health and/or psychosocially challenging issues”. The review suggests this should include “screening for neurological conditions, including autism spectrum disorder, and a mental health assessment”.
The idea of a holistic assessment has so far been welcomed by medical experts such as Dr Lade Smith, the president of the Royal College of Psychiatrists, who said: “Children who question gender also often experience mental illness. It is extremely important that every child facing gender questions has timely access to services that are holistic and responsive to their individual needs.”
But the proposals will have major implications for the wider children’s mental health system, which is already overstretched.
Waiting lists for gender-affirming care in the NHS are incredibly long. In August 2022, 26,234 adults were waiting for a first appointment with an adult gender dysphoria clinic, of whom 23,561 had been waiting more than 18 weeks. The number of children on the waiting list was approximately 7,600, of whom approximately 6,100 waited longer than 18 weeks.
In October, a coroner concluded that long waiting lists and barriers preventing trans people from accessing gender-affirming care in Britain contributed to a decline in the mental health of Alice Litman, a young trans woman who took her own life in 2022.
The Cass report recognizes that long waiting lists are a barrier to the NHS’s ability to provide effective gender-affirming care. It says: “Only when they have been on very long waiting lists and kept out of mainstream care in local services are they forced to do their own research and arrive at a single medical answer to their problems.”
However, general mental health care for young people is no better.
According to the Children’s Commissioner, more than a quarter of a million (270,300) children and young people in England are still waiting for mental health care after being referred to child and young people’s mental health services in 2022-2023.
Children and young people who had an appointment because they suspected autism had waited an average of nine months (295 days) after their first referral between July and September last year. This is despite the National Institute for Health and Care Excellence recommending that people with suspected autism should be diagnosed within three months of referral.
The Cass report said long waiting lists for gender services were partly due to an “unprecedented” increase in demand in recent years, creating “an unsustainable service model”. “Before 2009, Gids (the gender identity development service) did not attract much attention. At the time, the agency saw fewer than 50 children per year, and even fewer received medical treatment,” the report said.
Since the closure of the Guide clinic at Tavistock and Portman NHS Foundation Trust in London in 2023, NHS England has pledged to open eight regional clinics offering a “different model of care”. The report welcomes this, saying the regional centers should “enable care and risk to be actively managed… reducing waiting times for specialist care”. But with only one of these regional centers open, waiting lists will remain high for the foreseeable future.