When NHS England’s national youth gender identity clinic closed earlier this year, it had a caseload of around 650 children and young people. Amid controversy over how the clinic was run, the Gender Identity Development Service (Gids) – part of the Tavistock and Portman NHS Foundation Trust, and the only such centre for those under 18 in England and Wales – was shut down on 28 March, to be replaced by a number of regional healthcare centres. Some of the young people on its books were sent to two new NHS England gender identity hubs, based in London and Liverpool. The majority – around 400 – however, had their care moved elsewhere.
Of those, some 190 were already 17 and therefore could be transferred to adult gender clinics. The remainder – around 210 young patients – were on the “endocrine pathway” and receiving either puberty blocking drugs or hormones to help them medically transition. When pressed by the New Statesman in March, NHS England confirmed that this latter group would be cared for by a “wraparound service” provided by Nottinghamshire Healthcare NHS Foundation Trust. This service, NHSE said, would work to the same interim service specification as the new gender services, while “recognising that not all of it will apply to this patient cohort”. NHSE insisted that these children would receive psycho-social support, including mental health care.
So last week, when a job advert appeared for a clinical psychologist at that wraparound service, saying something rather different, eyebrows were raised. It seemed the provision – now called the Nottingham Young People’s Gender Service (NYGS) – was looking for a clinician whose approach would align with methods that had contributed to the Gids clinic becoming so controversial in the first place. The job ad said it was “essential” that candidates “practice [sic] in a gender affirming manner in line with” the World Professional Association for Transgender Health’s (WPATH) Standard of Care 8 (SOC-8)”.
The US-based World Professional Association for Transgender Health (WPATH), despite its name, does not advocate a settled global view on best practice in this area – there is no such consensus in gender medicine. Nevertheless, WPATH produces a set of guidelines for assessment and treatment, under the title Standards of Care for the Health of Transgender and Gender Diverse People (SOC) which, it claims, articulate a “professional consensus”. The most recent version – SOC-8 – does away with any recommended age limits for hormones and surgical interventions for young people, other than for female-to-male genital surgery. It also contains a chapter on “those who identify as eunuchs”.
In recent months, a raft of new information has emerged, thanks to court documents presented by the state of Alabama to the US Supreme Court, seeking to challenge the Biden administration’s policy on healthcare for young people seeking to medically or surgically transition gender. In making the state’s case, these documents shed light on how these standards of care were drafted, and why age limits were removed – having been included in the body’s previous recommendations. The documents assert, referencing original emails, that the US assistant secretary for health, Dr Rachel Levine, who is a trans woman herself, intervened in the drafting of SOC-8 and lobbied to have age limits removed. They also claim that WPATH “suppressed” the findings of several systematic evidence reviews into transgender healthcare undertaken by Johns Hopkins University, because the association did not like the results. The head of the team at Johns Hopkins reported: “[W]e found little to no evidence about children and adolescents.”
In her independent review of the NHSE’s gender identity services for young people, Dr Hilary Cass noted that while WPATH’S guidance had “been highly influential in directing international practice”, it was found to “lack developmental rigour”. The organisation “overstates the strength of the evidence” when making recommendations for treatment, the Cass Review’s final report states.
When the job advert went online, questions were raised in parliament – by the Labour peer Baroness Hayter in the Lords and the Conservative MP Nick Timothy in the Commons. Both pointed out that adherence to WPATH ran contrary to the findings of the Cass Review, and the way that NHSE has pledged to care for gender-questioning young people. There is no mention of WPATH in the service specification underpinning the new youth gender services for England and Wales. NHS England’s core recommendation that puberty blockers will no longer be available as part of routine clinical practice also run contrary to WPATH’s guidelines.
But the advert threw up further questions. It also said that some of the children were “awaiting… hormone blockers or hormones”, following assessment by Gids. Why are there children who have not yet commenced treatment? And how many of them are there? If they haven’t begun, why are they being allowed to start, given Cass’s findings that the evidence base for them is “remarkably weak”?
Several staff at Nottingham Centre for Transgender Health are not just members of WPATH, but helped write SOC-8. Professor Jon Arcelus, who is a doctor at the centre, was co-chair of the group devising the eighth edition of the guidelines. Walter Bouman, a consultant psychiatrist at Nottingham, is a former WPATH President, who has criticised the Cass Review: “Hillary [sic] has never treated trans youth, nor is she a researcher of any significance, yet her ‘expert’ review provides supposedly ‘evidence based’ recommendations… There is a fine line between naivety, narcissism, and psychopathy,” he wrote on social media in April. On 15 October Bouman signed an open letter to health secretary Wes Streeting expressing a group of clinicians’ “deep lack of confidence in the Cass Review”. Nottingham also declined to hand over data on former Gids patients under their care to the Cass Review.
I put a series of questions to NHS England, which commissioned this service, and to Nottinghamshire Healthcare NHS Foundation Trust, which now runs it. Neither provided answers on how many children were yet to commence medical treatment at NYGS or why their treatment was not under way. Why was the service apparently operating in line with WPATH’s SOC-8 and directly against the recommendations of the Cass Review? The answer provided was that “old terminology was used in the job advertisement” and that this was being amended. An NHS spokesperson said that the Nottingham service was not one of the children and young people’s gender services that had been commissioned in the wake of Gids’s closure, and that these new centres are being established closely in line with recommendations from the Cass Review.
Nottinghamshire Healthcare’s chief executive, Ifti Majid, said: “The Nottingham Young People’s Gender Service has been developed in line with NHS England’s national specification. This psychologist position is for a specialist to work with young people… to deliver psychological assessment and therapies in compliance with the recommendations set out in the Cass Review.”
The response baffled me. Old terminology? Really? The Cass Review’s final report was published six months ago, and yet there was no mention of the review in the job ad. The service was commissioned to work according to NHS England’s service specification – and NHS England has issued statements dismissing WPATH’s methodology. Gids itself never operated under WPATH’s SOC-8 guidelines. A spokesperson for Nottingham confirmed that the service would not be operating in accordance with SOC-8. One can only assume that the trust will now have to contact those who had already applied, explaining that unfortunately they have done so for a very different role. A newly worded job specification was posted on 21 October, with the requirement to practise according to WPATH SOC-8 removed.
Equally odd has been the government’s response, or lack of one. The Department for Health and Social Care did not respond to a request for comment from the New Statesman. When Nick Timothy raised the job advert during business questions, the Leader of the House, Lucy Powell, appeared to be answering another question entirely. “We must handle these issues carefully, as some young people and adults have real challenges with gender dysphoria that can cause them a great deal of mental upset,” she said. Timothy had simply pointed out that the Nottingham job advert ran “completely contrary to what the Cass Review said”. While the ad itself was “alarming”, Timothy told me, “It’s just as alarming that a cabinet minister was unwilling to endorse the Cass Review in parliament. We need urgent clarity on whether Cass is being implemented in the NHS, and whether the government still accepts the findings and recommendations.”
There is nothing to suggest that the government no longer accepts Cass’s findings and recommendations, but this episode should concern those who do. Crucial questions remain unanswered. Is NYGS starting children on puberty blockers or hormones? It would not say. How did the job advert get to be published on NHS England’s website with its initial wording? What care is being provided to these children?
I can’t help fearing that we have gone backwards: back to the days when a small group of children were not receiving the same level of care as others. These 200 or so children who have started a medical transition under a previous clinical model should not be forgotten. As they continue that process of transition, or choose to discontinue it, they will need support. That no one seems to know what is really going on is concerning. It was NHS England’s inability to provide proper oversight to the work of Gids that, in part, led to the mess we are currently in. So too was the abdication of responsibility by politicians. They all must do better this time.
[See also: Inside the collapse of the Tavistock Centre]
