The Tide Continues to Turn

In July 2022, it was announced that the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Trust in London would be closing down, following a letter from Dr Hilary Cass OBE – who is conducting an independent review into gender identity services on behalf of the government – to NHS England.

This was significant news and was met with support on all sides of the ongoing debate around sex and gender identity.

Concerns regarding the Tavistock have existed for many years and we have witnessed a number of whistle-blowers coming forward to raise what they saw as clinical and safeguarding failures around the unnecessary or ill-thought through medicalisation of children.

Equally, the waiting times to be seen at this one clinic were far too high – sometimes up to 2 years. Whatever one might think about the treatment pathway that a child with gender dysphoria should go down, we can all agree that 2 years for an appointment is far too long and in no one’s interest.

In the Tavistock’s place will be a ‘regional’ model, in which there will be, initially, two hubs – one in London and one in North-West England. This is due to take place by Spring 2023.

Dr Cass stated that the current Tavistock model left children “at considerable risk” of poor mental health and distress and that having a single clinic was not “a safe or viable long-term option”.

Concerns were raised by Dr Cass about the lack of peer review, good short and long-term data and adequate resourcing, particularly given the significant demand for the services. She went on to state that “the most important way to reduce risk, improve decision-making and manage uncertainty is through safe systems”.

One of the most crucial rationale behind the need for the new centres is that they should be multi-professional, in order to ensure ‘holistic’ care for the children who use these services. This has been a longstanding demand of those concerned with the medicalisation of children. Specifically, this will include mental health services and specialist services for children with autism, children who have experienced trauma and looked-after children. It will also ensure access to clinicians with specialism in endocrinology and fertility. This holistic, explorative approach should, we hope, ensure that children do not find themselves on a slippery slope towards medicalisation, where it is neither safe nor clinically appropriate.

Crucially, Dr Cass has also made some initial soundings around the use of puberty blockers and cross-sex hormones (although these will not be considered in full until the final Report, which is anticipated to be delivered sometime in 2023). She stated: “We therefore have no way of knowing whether, rather than buying time to make a decision, puberty blockers may disrupt that decision-making process”.

She goes on to raise a concern that puberty blockers may cause “brain maturation” to be “temporarily or permanently disrupted” and that this could significantly impact “the ability to make complex-risk laden decisions”.

The above raises significant question marks over the oft-cited statement that puberty blockers are 100% reversible.

She finishes by emphasising the extremely limited research that exists on the impact of puberty blockers on neurocognitive development.

These damning statements came in quick succession following the publication of the Interim Cass Report in March 2022. The crucial things to emerge from the Interim Report were:

  • An acknowledgement of the lack of consensus and open discussion about gender dysphoria and the appropriate clinical response.
  • A statement that clinicians should remain open and explore a patient’s experience.
  • An emphasis that clinicians working in both primary and secondary care told Dr Cass that “they feel under pressure to adopt and unquestioning affirmative approach and that this is at odds with the standard process of clinical assessment and diagnosis”.

To those of us who have been raising these concerns for months and years, there is finally vindication. Dr Cass has made it very clear where her concerns lie and the expectation of what these new ‘regional’ centres will offer. Those who seek to push ideology or an affirmation-only model have had their cards firmly marked.

In the intervening weeks since the announcement of the Tavistock closure we have also learnt that there is likely to be group legal action against the Tavistock. According to the law-firm, Pogust Goodhead, there will be hundreds or even thousands of young adults who plan to sue the Tavistock for the failings of care they experienced, particularly those who were “rushed into treatment without the appropriate therapy and involvement of the right clinicians meaning that they were misdiagnosed”.

This is the type of ‘class action’ that is most notably seen in the United States and it could have profound implications for the nature of treatment of children with gender dysphoria in the UK.

The signs are hopeful. However, we are not yet out of the woods. It will remain to be seen whether the new ‘regional’ centres deliver the change we have been assured of. Many of us are on tenterhooks to see exactly what features in Dr Cass’ Final Report. Most concerning of all remain the growing number of private clinics, such as GenderGP, which enable children to avail of puberty-blockers and cross-sex hormones outside of the NHS and for whom the concerns about safeguarding are the same as for the Tavistock, if not higher.

The tide continues to turn…

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