Following extensive stakeholder engagement and a systematic review of evidence, England’s National Health Service (NHS) has issued new draft guidance for the treatment of gender dysphoria in minors, which sharply deviates from the “gender-affirming” approach. The previous presumption that gender dysphoric youth <18 need specialty “transgender healthcare” has been supplanted by the developmentally-informed position that most need psychoeducation and psychotherapy. Eligibility determination for medical interventions will be made by a centralized Service and puberty blockers will be delivered only in research protocol settings. The abandonment of the "gender-affirming" model by England had been foreshadowed by The Cass Review's interim report, which defined "affirmative model" as a "model of gender healthcare that originated in the USA."
The reasons for the restructuring of gender services for minors in England are 4-fold. They include (1) a significant and sharp rise in referrals; (2) poorly-understood marked changes in the types of patients referred; (3) scarce and inconclusive evidence to support clinical decision-making, and (4) operational failures of the single gender clinic model, as evidenced by long wait times for initial assessment, and overall concern with the clinical approach.
The new NHS guidance recognizes social transition as a form of psychosocial intervention and not a neutral act, as it may have significant effects on psychological functioning. The NHS strongly discourages social transition in children, and clarifies that social transition in adolescents should only be pursued in order to alleviate or prevent clinically-significant distress or significant impairment in social functioning, and following an explicit informed consent process. The NHS states that puberty blockers can only be administered in formal research settings, due to the unknown effects of these interventions and the potential for harm. The NHS has not made an explicit statement about cross-sex hormones, but signaled that they too will likely only be available in research settings. The guidelines do not mention surgery, as surgery has never been a covered benefit under England’s NHS for minors.
The new NHS guidelines represent a repudiation of the past decade’s approach to management of gender dysphoric minors. The “gender-affirming” approach, endorsed by WPATH and characterized by the conceptualization of gender-dysphoric minors as “transgender children” has been replaced with a holistic view of identity development in children and adolescents. In addition, there is a new recognition that many gender-dysphoric adolescents suffer from mental illness and neurocognitive difficulties, which make it hard to predict the course of their gender identity development.
The key highlights of the NHS new guidance are provided below.*
1. Eliminates the “gender clinic” model of care and does away with “affirmation”
- The NHS has eliminated the “gender clinic” model of care where children are seen solely by a specialist gender dysphoria practitioner, replacing it with standard care in children’s hospital settings.
- Rather than “affirming” a transgender identity of young person, staff are encouraged to maintain a broad clinical perspective and to “embed the care of children and young people with gender uncertainty within a broader child and adolescent health context.”
- “Affirmation” has been largely eliminated from the language and the approach. What remains is the guidance to ensure that “assessments should be respectful of the experience of the child or young person and be developmentally informed.”
- Medical transition services will only be available through a centralized specialty Service, established for higher-risk cases. However, not all referred cases to the Service will be accepted, and not all accepted cases will be cleared for medical transition.
- Treatment pathway will be shaped, among other things, by the “clarity, persistence and consistency of gender incongruence, the presence and impact of other clinical needs, and family and social context.”
- The care plan articulated by the Service will be tailored to the specific needs of the individual following careful therapeutic exploration and “may require a focus on supporting other clinical needs and risks with networked local services.”
2. Classifies social gender transition as an active intervention eligible for informed consent
- The NHS is strongly discouraging social gender transition in prepubertal children.
- The qualifying criteria for social gender transition in adolescence are:
- diagnosis of persistent and consistent gender dysphoria
- consideration and mitigation of risks associated with social transition
- clear and full understanding of the implications of social transition
- a determination of medical necessity of social transition to alleviate or prevent clinically significant distress or impairment in social functioning
- All adolescents will need to provide informed consent to social gender transition.
3. Establishes psychotherapy and psychoeducation as the first and primary line of treatment
- All gender dysphoric youth will first be treated with developmentally-informed psychotherapy and psychoeducation by their local treatment teams.
- Extensive focus has been placed on careful therapeutic exploration, and addressing the broader range of medical conditions in addition to gender dysphoria.
- For those wishing to pursue medical transition, eligibility for hormones will be determined by a centralized Service, upon referral from a GP (general practitioner) or another NHS provider.
4. Sharply curbs medical interventions and confines puberty blockers to research-only settings
- The NHS guidance states that the risks of puberty blockers are unknown and that they can only be administered in formal research settings. The eligibility for research settings is yet to be articulated.
- The NHS guidance leaves open that similar limitations will be imposed on cross-sex hormones due to uncertainty surrounding their use, but makes no immediate statements about restriction in cross-sex hormones use outside of formal research protocols.
- Surgery is not addressed in the guidance as the NHS has never considered surgery appropriate for minors.
5. Establishes new research protocols
- All children and young people being considered for hormone treatment will be prospectively enrolled into a research study.
- The goal of the research study to learn more about the effects of hormonal interventions, and to make a major international contribution of the evidence based in this area of medicine.
- The research will track the children into adulthood.
6. Reinstates the importance of “biological sex”
- The NHS guidance defines “gender incongruence” as a misalignment between the individual’s experience of their gender identity and their biological sex.
- The NHS guidance refers to the need to track biological sex for research purposes and outcome measures.
- Of note, biological sex has not been tracked by GIDS for a significant proportion of referrals in 2020-2021.
7. Reaffirms the preeminence of the DSM-5 diagnosis of “gender dysphoria” for treatment decisions
- The NHS guidance differentiates between the ICD-11 diagnosis of “gender incongruence,” which is not necessarily associated with distress, and the DSM-5 diagnosis of “gender dysphoria,” which is characterized by significant distress and/or functional impairments related to “gender incongruence."
- The NHS guidance states that treatments should be based on the DSM-5 diagnosis of “gender dysphoria.”
- Of note, WPATH SOC8 has made the opposite recommendation, instructing to treat based on the provision of the ICD-11 diagnosis of “gender incongruence.” “Gender incongruence” lacks clinical targets for treatment, beyond an individual’s own desire to bring their body into alignment with their internally-held view of their gender identity.
8. Clarifies the meaning of “multidisciplinary teams” as consisting of a wide range of clinicians with relevant expertise, rather than only “gender dysphoria” specialists
- The NHS guidance clarifies that a true multidisciplinary team is comprised not only of “gender dysphoria specialists,” but also of experts in pediatrics, autism, neurodisability and mental health, to enable holistic support and appropriate care for gender dysphoric youth.
- Such multidisciplinary teams will be the hallmark of the new Service, into which challenging and risky cases may be referred. In addition to specific expertise in gender identity development and incongruence, the clinical leadership teams of the newly-established Service will include strong, “consultant level” expertise in a wide range of relevant areas:
- neurodevelopmental disorders such as autistic spectrum conditions
- mental health disorders including depressive conditions, anxiety and trauma
- endocrine conditions including disorders of sexual development pharmacology in the context of gender dysphoria
- risky behaviors such as deliberate self-harm and substance use
- complex family contexts including adoptions and guardianships
- a number of additional requirements for the multidisciplinary team composition and scope of activity have been articulated by the NHS.
9. Establishes primary outcome measures of “distress” and “social functioning”
- The rationale for medical interventions for gender-dysphoric minors has been a moving target, ranging from resolution of gender dysphoria to treatment satisfaction. The NHS has articulated two main outcome measures of treatment: clinically significant distress and social functioning.
- This is an important development, as it establishes primary outcome measures that can be used by researchers to assess comparative effectiveness of various clinical interventions.
10. Asserts that those who choose to bypass the newly-established protocol will not be supported by the NHS
- Families and youth planning to obtain hormones directly from online or another external non-NHS source will be strongly advised about the risks.
- Those choosing to take hormones outside the newly established NHS protocol will not be supported in their treatment pathway by NHS providers.
- Child safeguarding investigations may also be initiated if children and young people have obtained hormones outside the established protocols.
With the new NHS guidance, England joins Finland and Sweden as the three European countries who have explicitly deviated from WPATH guidelines and devised treatment approaches that sharply curb gender transition of minors. Psychotherapy will be provided as the first and usually only line of treatment for gender dysphoric youth.
The full text of the NHS guidance can be accessed here.
* This is a transitional protocol as the NHS works to establish a more mature network of children’s hospitals capable of caring for special needs of gender dysphoric youth. A fuller service specification will be published in 2023-4 following the publication of the Cass Review’s final report.