The NHS published its proposed Interim Service Specification for the treatment of ‘gender dysphoria’ on 20th October 2022
The NHS is consulting on this Interim Service Specification for what they are calling Specialist service for children and young people with gender dysphoria (phase 1 providers)
The consultation runs from 20th October 2022 to 4th December 2022
The consultation is now closed and our final submission can be read here.
Our initial response is a good place to start and can be found here.
Read the proposed Interim Service Specification here
Read the Consultation Guide
Equality and Health Inequalities Impact Assessment
This is our brief guidance, for a chance to investigate further both the consultation and the Our Duty response, see The Consultation below.
Guidance
NHS England would like to hear what patients, parents and carers, clinicians, providers and other interested parties think about the proposed interim service specification for gender dysphoria services.
There is much to welcome in the proposed Interim Service Specification. In the interests of brevity and clarity we have chosen to omit responses which would merely agree with or welcome specific proposals.
These are the questions they are asking as part of the public consultation:
1. In what capacity are you responding?
(Patient / Parent / Clinician / Service Provider / Other; If you have selected ‘Other’, please specify.)
2. Are you responding on behalf of an organisation?
(yes / no; If you have selected “yes”, which organisation are you responding on behalf of?)
3. To what extent do you agree with the four substantive changes to the service specification explained above?
A. Composition of the clinical team
(Agree / Partially Agree / Neither Agree nor Disagree / Partially Disagree / Disagree; comments)
Partially Agree
No endocrinologists needed.
It is possible that a child or young person might have developed transgender ideation because they have a pre-existing hormone imbalance causing them dissatisfaction with their body as it undergoes puberty. In such circumstances endocrine intervention might be appropriate but only for the reason to better align the patient’s body with the stereotypical morphology for their sex. The patient is unlikely to desire such intervention while suffering from transgender ideation, however, such an intervention might contribute to a resolution of their transgender ideation. In such a scenario, the parent’s role is crucial.
B. Clinical leadership
(Agree / Partially Agree / Neither Agree nor Disagree / Partially Disagree / Disagree; comments)
Partially Agree
The Clinical Lead for each Phase 1 Service MUST be ‘gender critical’. i.e. they must understand that sex is binary and immutable and that transgenderism tends to be:
- a maladaptive coping mechanism,
- acquired through peer contagion, frequently online,
- arrived at after much rumination,
- influenced by copious misinformation.
We recognise that this recruitment criterion is discriminatory, however it should pass the objective justification test of a ‘proportionate means of achieving a legitimate aim’. Protecting children and young people from the harms of gender identity ideology is the aim.
C. Collaboration with referrers and local services
(Agree / Partially Agree / Neither Agree nor Disagree / Partially Disagree / Disagree; comments)
Partially Agree
There is a danger of referring GPs who do not have sufficient knowledge in this domain to ensure patients are not referred to the service when they do not need to be. There are activist GPs who will likely refer everyone, GPs who believe in Gender Identity Ideology (especially since GLADD is pushing it to be taught in Medical Schools) who will likely refer everyone, and some GPs who understand the issues and will likely prefer to refer nobody, instead preferring the underlying conditions to be dealt with locally and with zero risk of a medical pathway.
Local services need to be built from scratch. Existing services, particularly CAMHS have been ideologically captured by the gender identity movement. There cannot be anybody who believes that someone can actually *be* transgender involved in the clinical care of somebody who thinks they are.
D. Referral sources
(Agree / Partially Agree / Neither Agree nor Disagree / Partially Disagree / Disagree; comments)
Partially Agree
There needs to be a reporting mechanism such that when an unregulated source is brought to the attention of NHS Practitioners, a regulatory investigation can be launched with a view to closing down that source, and where appropriate prosecuting the persons with ultimate control.
The safeguarding procedure that must be followed needs to entirely focused on protecting the child from any further harm and removing access to medicines from unregulated sources.
Breast binders should be made Prescription Only Medicine (POM).
4. To what extent do you agree that the interim service specification provides sufficient clarity about approaches towards social transition?
(Agree / Partially Agree / Neither Agree nor Disagree / Partially Disagree / Disagree; comments)
Neither Agree nor Disagree
There needs to be more explicit discouragement of social transition, and such discouragement must not be restricted to pre-pubertal children but must encompass all adolescents. Fewer children and young people will present with transgender ideation of the very idea that someone can be transgender (as a diagnosable medical condition distinct from a social affinity) is not promoted in schools and wider society. While ensuring such might be beyond the remit of this proposed Service, it needs to be a point of view that The Service is empowered to promote as part of its remit of prevention.
5. To what extent do you agree with the approach to the management of patients accessing prescriptions from un-regulated sources?
(Agree / Partially Agree / Neither Agree nor Disagree / Partially Disagree / Disagree; comments)
Partially Agree
There needs to be a reporting mechanism such that when an unregulated source is brought to the attention of NHS Practitioners, a regulatory investigation can be launched with a view to closing down that source.
The safeguarding procedure that must be followed needs to entirely focused on protecting the child from any further harm and removing access to medicines from unregulated sources.
Breast binders should be included as items so controlled.
6. Are there any other changes or additions to the interim service specification that should be considered in order to support Phase 1 services to effectively deliver this service?
(comments)
The Interim Service Specification must:
- Better differentiate between prepubescent and adolescent cohorts.
- Recognise that opposite sex imitation is not proper medicine for the treatment of transgender ideation.
- Extend the adolescent cohort to include those up to age 25.
- Be more emphatic in discouraging ‘social affirmation’.
- Remove the possibility of Gonadotropin-Releasing Hormone Analogues (a.k.a. ‘puberty blockers’) being administered to children for reasons of transgender ideation or for medical experiments on children.
- Remove the possibility of wrong-sex hormones being administered to children or adolescents for reasons of transgender ideation.
- Remove the possibility of opposite-sex imitation surgical interventions being administered to children or adolescents for reasons of transgender ideation.
- Not use ideological language.
- Explicitly target desistance from transgender ideation as the desired outcome.
THE LANGUAGE USED!
The language of the proposed Interim Service Specification indicates an adherence to gender ideology. Such politicised language must be removed and replaced with that which is objective and universally understood.
- There should be no use of ‘assigned [sex] at birth’ – sex is binary, determined at fertilisation and immutable.
- The word gender should not be used.
- The DSM-5 definition of Gender Dysphoria is not a suitable diagnostic tool.
7. To what extent do you agree that the Equality and Health Inequalities Impact Assessment reflects the potential impact on health inequalities which might arise as a result of the proposed changes?
(Agree / Partially Agree / Neither Agree nor Disagree / Partially Disagree / Disagree; comments)
How to Respond
You can provide your views with NHS England by completing the online survey:
https://www.engage.england.nhs.uk/specialised-commissioning/gender-dysphoria-services/consultation/
Your views will help NHS England to further shape and refine this interim service specification for gender dysphoria services, until a new service specification is agreed in 2023, which will be informed by a full consultation and engagement process.
The Consultation
This is an abridged version of the Consultation Guide.
The NHS is establishing two ’Phase 1’ services. These services will be led by specialist
children’s hospitals and, once established, will take over clinical responsibility for and
management of all current GIDS patients as part of a managed transition, and they
will begin to see children and young people who are currently on the GIDS waiting
list.
One Phase 1 service will be based in London and will be led by a partnership
between Great Ormond Street Hospital for Children NHS Foundation Trust and
Evelina London Children’s Hospital (part of Guys and St Thomas’ NHS Foundation
Trust), with South London and Maudsley NHS Foundation Trust providing specialist
CYP mental health support.
A second Phase 1 service will be based in the North West, led by a partnership
between Alder Hey Children’s NHS Foundation Trust and the Royal Manchester
Children’s Hospital (part of Manchester University NHS Foundation Trust), where
both trusts also provide specialist CYP mental health services.
The Phase 1 services will be commissioned against an interim service specification
which will replace the current service specification used by the GIDS.
There is now an urgent need to agree this specification to give the Phase 1 services time to recruit staff and set up the new services a quickly as possible.
The Four Substantive Changes Proposed
A. Composition of the clinical team
The current service specification for GIDS describes that the service is delivered through a specialist multidisciplinary team with contributions from specialist social workers, family therapists, psychiatrists, psychologists, psychotherapists, paediatric and adolescent endocrinologists and clinical nurse practitioners. The new interim service specification proposes to extend the clinical team so that it is a more integrated multi-disciplinary team that, in addition to gender dysphoria specialists, will include experts in paediatric medicine, autism, neurodisability and mental health.
B. Clinical leadership
The current service specification for GIDS does not describe criteria for the clinical lead for the service. The new interim service specification proposes that the clinical lead for the service will be a medical doctor.
C. Collaboration with, and support for, referrers and local services
The new interim service specification proposes a tiered approach to progression through the pathway and describes a more structured approach for collaboration with local services in the interests of the child and young person; a referral to The Service will require a consultation meeting between the Phase 1 service and the relevant local secondary healthcare team and / or the GP. Where the outcome of the initial professional consultation between the Service and the referrer is that the patient does not meet the access criteria for The Service, the child or young person will not be added to the waiting list – but the family and professional network will have been assisted to develop their formulation of the child or young person’s needs and a local care plan and will be advised of other resources for support that are appropriate for individual needs. The proposed interim service specification also proposes that not all children and young people who meet the access criteria will need to be seen directly by The Service. A key intervention that will be delivered by The Service is the provision of consultation and active support to local professionals, including support in formulation of needs and risks and individualised care planning. The level and type of consultation offered to the professional network will be determined according to the individual needs of each case and through a process of clinical prioritisation.
D. Referral sources
The current service specification for GIDS states that referrals can be made by staff
in health and social services, schools, colleges of further education and by voluntary
organisations. The new interim service specification proposes that referrals may be
made by GPs and NHS professionals.
Additional Proposals
Dr Cass has recommended that social transition be viewed as an ‘active intervention’ because it may have significant effects on the child or young person in terms of their psychological functioning. In line with this advice, the interim service specification sets out more clearly that the clinical approach in regard to pre-pubertal children will reflect evidence that in most cases gender incongruence does not persist into adolescence; and that for adolescents the provision of approaches for social transition should only be considered where the approach is necessary for the alleviation of, or prevention of, clinically significant distress or significant impairment in social functioning and the young person is able to fully comprehend the implications of affirming a social transition.
Additional Response from Our Duty
Our response is based upon this simple question:
“Do the proposed Interim Service Specifications meet the requirement for children and adolescents to be safe from the risk of unnecessary medical harm resulting from transgender ideation?”
Knowing as we do that the NHS is financially constrained, and that talking therapies and consultations are, in the short to medium term, more expensive than drugs and surgeries, we must be alert to how any proposed service will be delivered.
There will be financial pressure for consultations and therapy courses to be short.
There is no mention in the proposed specifications as to how well the localised ‘pre-referral’ support will be built and financed. Moreover, we know that existing facilities e.g. CAMHS and CYPMHS are irredeemably ‘captured’ by transgender ideology. There is a clear risk that youngsters entering this system will, as before, be affirmed in their spurious “gender identity” and put on a waiting list, despite the provisions of the new guidance. The proposed interim service specification fails to address how this culture will not pervade through the new service as it has done so in its predecessor.
The proposed follow-up for youth does not explicitly preclude treatment with hormones and surgeries.
In relying on the widely discredited DSM 5 definition of ‘gender dysphoria’ as a test for entry onto a medical pathway, it is unclear that children will be any safer. The failure to extend the service to those 25 and under (despite being advocated in the NHS Long Term Plan for Mental Health) demonstrates both an ignorance of the factors at play and a disregard for the safeguarding of all vulnerable adolescents.
Just as the inception of The Cass Review was not accompanied by an immediate moratorium on opposite sex imitation (despite the former being a clear admission that something very wrong had been noticed), the failure of this proposed Interim Service Specification to display proper understanding of the realm of adolescent transgender ideation reinforces the idea that this is all for show.
The NHS is marginally safer now (thanks to Keira Bell) than when the Cass Review was first mooted three years ago, and in that timeframe countless youngsters have been medicalised unnecessarily.
The Service will provide multidisciplinary assessment and care to children and young
Specialist service for children and young people with gender dysphoria (phase 1 providers) : S.5 Summary
people and their families who will benefit from clinical support around the development of their gender identity, and interventions in response to a diagnosis of gender dysphoria, and consultation and support to local professionals.
The whole concept of ‘gender identity’ is grounded in political ideology. A child or young person presenting with one has been indoctrinated to believe that they have a ‘gender identity’ – this does not need “developing” – rather it needs erasing.
The language of the proposed Interim Service Specification includes terms like gender incongruence, and gender dysphoria. There is no diagnosis for gender dysphoria and the DSM-5’s very definition of gender is alarmingly vague. This might have a lot to do with gender being an artificial construct and not a real or measurable human attribute. If gender is a ‘sense of self’ then if that is at odds with the reality of a person’s sex, then it is that ‘sense’ which demands rectification. Twice in the DSM-5 they write, or ‘another gender’. What gender, where? Then what is gender, and how are its constituents defined and categorised?
The report recommends documenting the nature of gender incongruence, nearly as a footnote, under 7.1. However, since this proposal is all about how this phenomenon – which we prefer to call transgender ideation – is to be treated by the NHS, then specifying such a service requires a solid and thorough description of the problem front and centre. Such a description must be “bulletproof” both in language, logic and the evidence base behind it. Unlike the the official NHS definition of “Gender Dysphoria”.
Among claims of prudence, phrases such as ‘potential benefits of GnRHA’, ‘desired social transition’, ‘subsequent physical interventions’ hit the reader in the face.
The role of society in shaping gender problems is underplayed. Social care involvement needs more references made to, earlier on in the report. The implications of a biological basis for gender non conformity is fully retained (despite there being no evidence to support that hypothesis). Thus gender remains shrouded in the thickest mystery while people are expected to pretend not to notice.
Mentions of safeguarding are numerous but unconnected to any concrete issues, least of all parental conflicts, inter generational pathology and trauma. Trauma has become taboo. Trauma is one of the main contributors to susceptibility to transgender ideation.
The proposal makes no mention of same sex attractions. Yet these stand at the root of most transgender ideations. Homophobia in parents and the community ought to be addressed. Instead, a lame “facilitate understanding and acceptance in the family unit” (under Direct work with young people and families) is put vaguely forward.
