Following an independent review by paediatrician Dr. Hilary Cass, the NHS is shutting down its Gender Identity Development Service for Children and Adolescents (GIDS) at the Tavistock & Portman NHS Foundation Trust. The GIDS provides support for young people who ‘experience difficulties in the development of their gender identity’, and for their families.
As referrals to the GIDS have skyrocketed over the past decade - 5000 over the past year, up from 250 in 2011/12 - the centre has become a topic of public discussion, and its services subject to significant scrutiny.
Emerging discussions about gender identity across many parts of the world foreshadow cultural progression towards a more flexible and open conception of gender. But discussions around the topic have proved difficult to have, with a spectrum of conceptions, ideas and concerns often causing divisiveness.
The GIDS is perceived by many to be especially controversial given that it deals specifically with children and adolescents. The centre provides support to its patients predominantly in the form of psychotherapy, intended to support children in understanding and feeling comfortable with their gender identity. But the centre also provides access to hormonal treatment. Whether or not, and from what age, young people have legitimate capacity to make decisions about gender-affirming hormone treatment - so taking hormone blockers to delay puberty, or cross sex hormones to transition to the opposite sex - has been a central concern. There is a lack of clarity around the long-term effects of puberty blockers: they are not necessarily a simple ‘pause-button’ which guarantees that puberty will continue in the same way after the patient ceases to use the blockers.
In 2021, a case was brought before the Court of Appeal by 23 year-old Keira Bell, a former patient of the Tavistock centre. She was put on puberty blockers at 16 and received testosterone shots to transition from male to female a year later. At 20, she had a double mastectomy. But later on, she came to realise that she regretted the transition: “I recognized that gender dysphoria was a symptom of my overall misery, not its cause”, she wrote in an article in 2021.
Bell’s claim before the court was that children under the age of 18 cannot give informed consent to treatment with puberty blockers. The case drew significant public attention and commentary, but the ruling upheld the existing law: 16 and 17 year olds are presumed to have the capacity to give legally effective consent to treatment for hormone blockers or cross-sex hormones.
So if the GIDS survived a high-profile, high-scrutiny case like Tavistock v Bell, why is it closing down now? Dr. Hilary Cass’ independent report criticises the centre on a structural and organisational basis. The exponential increase in referrals to the GIDS has not been matched by sufficiently evolved treatment plans or staff numbers and has put pressure on staff to “adopt an unquestioning affirmative approach.” Because the service has evolved so quickly in response to demand, it has not been subjected to the regulatory and procedural review that clinical services should be. There is a lack of consensus on the ‘correct’ treatment model: ultimately, there is no concrete measure for whether the GIDS’ services have been carried out to an adequate standard.
This means that on the one hand, adolescents facing gender dysphoria are at a risk of rushing into hormone therapy without meticulous assessment and adequate support, and on the other hand, waiting lists are so long that many adolescents wait longer than they should for the counselling and treatment that they need. Either of these outcomes considerably risks the deterioration of mental health for present and prospective GIDS patients.
So what support can trans adolescents expect from the NHS in the future? According to Dr. Cass, “a single specialist provider model is not a safe or viable long-term option.” Instead, She has recommended the installation of several regional hubs. Smaller scale centres should allow for better organisation and higher staff to patient ratio, ensuring patients will get an adequate level of attention. Following Dr. Cass’ suggestion, the NHS is to instate two new clinics by 2023: one in London and one in Manchester. Three more hubs are projected to open later on.
As reported by the Guardian, waiting lists will likely remain “painfully long” despite assurances of a smooth transition between the current and future model. There are concerns that it is “unlikely that the impact of the new hubs will be felt for some time”.
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