NHS service specification: A dangerous attack on trans kids

NHS England has just released a consultation on a revised Service Specification for trans children and adolescent health care.

The revised specification is dangerous, ideologically-driven, and will cause serious harm to trans kids in the UK.

There are many many deficiencies and areas of outrage in the draft.

It has been written with dangerous bad intent (I wonder who in NHS England wrote it).

We need collective action to fight for trans kids’ rights, so I’m putting my work-in-progress analysis here for others to build from.

I have divided my feedback into 27 categories:

1. Inclusion of outdated and ill-informed presumptions on trans children’s identities.

2. Omission of modern & relevant evidence on trans children’s identities

3. Inclusion of outdated, mis-placed & mis-interpreted evidence on social transition

4. Omission of modern & relevant evidence on social transition

5. Cisnormative, pathologising, unevidenced approach to social transition being an ‘intervention’

6. Omission of harms of denied transition

7. Fails to condemn conversion practices

8. Pathologising & incompatible with ICD-11

9. Intrusive and inappropriate assessment

10. Redefining EA2010 protections to remove & medicalise rights for trans children

11. Misapplication of ‘safeguarding’ to threaten access to life-saving healthcare

12. Ignorant of flaws in dysphoria definitions

13. Ignorant of potential for harm in adding extra GP layer into referral

14. Ignorant of harms of denial of healthcare

15. No centring of child rights to healthcare

16. No centring of healthcare accountability or mechanisms to empower service users

17. Presentation of psychoeducation as treatment for dysphoria

18. No emphasis on psycho education to raise trans positivity

19.  No centring disability & neurodiversity rights

20. Failure to recognise gender minority stress as key driver of mental health differentials

21. Suggests intrusive search for causation

22. Leaves space for gender exploratory therapy

23. Uses dated and unscientific language for ideological purposes to illegitimise and disenfranchise

24. Emphasis on MDT

25. Failure to centre endocrine care pathways

26. Failure to engage with trans expertise

27. Under-planning for expected population

  1. Inclusion of outdated and ill-informed presumptions on trans children’s identities.

[Service spec page 1] “clinical support around the development of their gender identity”.

Framing support for trans children around ‘development’ of their gender identity is ill-informed, prejudiced against trans people, and unrepresentative of the modern evidence base (see point 2 below)

[Service spec page 2] “being mindful that this may be a transient phase, particularly for pre-pubertal children”.

This statement is unreferenced, and does not align with modern evidence (see point 2). Documents that do provide a citation for such a claim tend to rely on a number of very old citations that used old diagnoses that included children who were gender non-conforming rather than trans. A majority of these children did not end up trans because they were not trans in the first place. Using older research to claim that trans children’s identity is likely to be a transient phase is harmful bad science, at best a misunderstanding of the meaning of the older evidence base, at worst the knowing mis-representation of older evidence for ideological goals.  

[service spec page 8] “research will include” “prediction” “the course of gender querying”

The service’s research goals are aligned with cis people’s fears, not with trans children and adolescent’s needs.

[service spec page 8] “an individual’s route will be determined by…. The clarity, persistence and consistency of gender incongruence”.

This requirement discriminates against trans children who assert their identity at puberty, those who were not distressed in early childhood, those whose families do not recognise the period of their distress, those who need healthcare without being currently distressed, and those who hid their identity out of fears of rejection or societal judgement. It also fails to consider the timeliness of healthcare needs especially for those experiencing an significant increase in distress at the point of puberty, and the fact that interventions such as puberty blockers are particularly valuable for those adolescents who arrive at the service at the cusp of puberty with fear and distress requiring immediate access to puberty blocking support.

[service spec page 12] “assessments will focus on the child’s understanding of gender”

Trans children do not need to have a theoretical or conceptual understanding of gender and should not be expected to demonstrate to clinicians an understanding of gender. Existing research shows that children experience intrusive questioning on gender irrelevant, intrusive and harmful.

[service spec page 13] “psycho-education material for children, parents… will include information on gender identity development including research evidence and how to support an exploratory approach”.

Given how poorly this service spec reflects existing evidence, I would be extremely concerned about the materials provided to parents. Misguided and misinformed information sent to parents will cause harm and undermine support for trans children.

[service spec page 13] “the clinical approach in regard to pre-pubertal children will reflect evidence that suggests that… in most pre-pubertal children, gender incongruence does not persist into adolescence”.

The above cites the Endocrine Society statement “combining all outcome studies to date, gender incongruence of a minority of prepubertal children appears to persist in adolescence”.

It is important to note that the Endocrine guidelines themselves provide a longer quote on this topic

“However, the large majority (about 85%) of prepubertal children with a childhood diagnosis did not remain GD/ gender incongruent in adolescence (Source: Steensma TD, Kreukels BP, de Vries AL, Cohen-Kettenis PT. Gender identity development in adolescence. Horm Behav. 2013; 64(2):288–297.

Prospective follow-up studies show that childhood GD/gender incongruence does not invariably persist into adolescence and adulthood (so-called “desisters”). In adolescence, a significant number of these desisters identify as homosexual or bisexual. It may be that children who only showed some gender nonconforming characteristics have been included in the follow-up studies, because the DSM-IV text revision criteria for a diagnosis were rather broad. However, the persistence of GD/gender incongruence into adolescence is more likely if it had been extreme in childhood (41, 42). With the newer, stricter criteria of the DSM-5 (Table 2), persistence rates may well be different in future studies.”

The NHS has here chosen to omit the important clarification within the Endocrine guidelines, that highlights that even back in 2017 it was recognised that the ‘desistance’ statistics rely on old definitions that focused on gender non-conforming children rather than trans children, and that newer studies focused specifically on trans children expect to find a different outcome.

The citation about collective studies showing high rates of desistance from the 2017 Endocrine society cites a 2013 study by Steensma, which in turn cites a 2011 literature review again by Steensma.

Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT. Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study. Clinical Child Psychology and Psychiatry. 2011;16(4):499-516. doi:10.1177/1359104510378303

In this 2011 literature review, statistics are drawn from studies published in 1968, 1972, 1979, 1984, 1986, 1987, 1987, 1995, 2008, 2008. The vast majority were published last millennium, drawn from research conducted even earlier, research that focused on gender non-conforming children who were problematised lest they grow up to be gay. Several of those studies were outright conversion therapy studies for gender non-conforming children, with methods that were coercive and abusive.

Ten studies are included in the 2011 literature review and these are the ten studies upon which the NHS is basing 2022 clinical practice. Take a look at the titles of these ten studies:  

Bakwin H. (1968). Deviant gender-role behavior in children: Relation to homosexuality. Pediatrics, 41, 620–629.

Davenport C. W. (1986). A follow-up study of 10 feminine boys. Archives of Sexual Behavior, 15, 511–517.

Drummond K. D., Bradley S. J., Peterson-Badali M., Zucker K. J. (2008). A follow-up study of girls with gender identity disorder. Developmental Psychology, 44, 34–45.

Green R. (1987). The “Sissy Boy Syndrome” and the development of homosexuality. New Haven, CT: Yale University Press.

Kosky R. J. (1987). Gender-disordered children: Does inpatient treatment help? Medical Journal of Australia, 146, 565–569.

Lebovitz P. S. (1972). Feminine behavior in boys: Aspects of its outcome. American Journal of Psychiatry, 128, 1283–1289.

Money J., Russo A. J. (1979). Homosexual outcome of discordant gender identity/role: Longitudinal follow-up. Journal of Pediatric Psychology, 4, 29–41.

Wallien M. S. C., Cohen-Kettenis P. T. (2008). Psychosexual outcome of gender-dysphoric children. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 1413–1423.

Zucker K. J., Bradley S. J. (1995). Gender identity disorder and psychosexual problems in children and adolescents. New York: Guilford Press.

Zuger B. (1984). Early effeminate behavior in boys: Outcome and significance for homosexuality. Journal of Nervous and Mental Disease, 172, 90–97.

Even from the project titles you can see these early research projects had a problem with femininity, ‘sissy-ness; ‘effeminancy’ or ‘proto-homosexuality’ in boys. These were not research projects on trans kids, but on kids who were deemed insufficiently masculine, many with explicit goals of teaching young boys to toughen up to prevent them becoming a ‘homosexual deviant’. The fact that many of these young boys grew up to be gay men rather than trans women tells us nothing about outcomes for today’s trans kids.

The authors of the above studies are also synonymous with key figures in conversion practices, especially conversion practices to try to prevent homosexual outcomes. Bryant, the child who in the 1970s was at the centre of the ‘sissy boy’ research project (Green, 1987, included above) went on to in the 2000s write his PhD on the damage of this research, how he felt rejected and coerced and was deeply harmed (see Bryant, 2005).

These abusive studies predominantly on boys who were deemed insufficiently masculine are entirely meaningless in driving clinical practice for trans kids in 2022. Why are they guiding clinical practice on trans kids and social transition in 2022? And why does the NHS cite them via a citation in a 2017 Endocrine Society endocrine guidance note that cites a 2011 literature review that cites the above texts, rather than actually owning up to based clinical practice on 50 year old conversion therapy literature?

I’ve been writing about this for over 5 years see https://growinguptransgender.com/2017/03/04/a-plea-for-better-transgender-research-on-the-perpetual-myth-of-desistance-and-the-harm-of-social-transitioning/

In the time since the publication of the Endocrine guidelines in 2017, the validity of the claim that trans children ‘desist’ in their identities has been strongly critiqued in the literature.

Even focusing just on the more recent of those studies, those published in 2008, gives serious cause for concern, with those studies widely condemned as both flawed and misinterpreted (Ehrensaft et al., 2018; Priest, 2019; Temple Newhook et al., 2018a, 2018b), critiqued for “methodological, theoretical, ethical, and interpretive concerns” (Temple Newhook et al., 2018a, p. 1). 

These older statistics on ‘desistance’ are also challenged by more modern research, with recent longitudinal studies from Australia (Tollit et al., 2021), USA (Olson et al., 2022) and Spain (De Castro et al., 2022) showing a large majority of trans and non-binary children and adolescents continuing to identify as trans or non-binary (96% across child and adolescent age groups in Australia over a ten-year period, 97.5% of children under 12 at 5 year follow up in the USA, and 97.6% of children and adolescents at 2.6 year follow up in Spain). 

[service spec page 13] “the approach will focus on careful observation of how gender dysphoria develops as puberty approaches and is reached”.

This statement that gender dysphoria needs to be observed (and the inference it is likely to change or desist) as puberty approaches is not evidenced.

Within older literature there is one study that mirror this language, which is now considered discredited as a source on this topic.

Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT. Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clin Child Psychol Psychiatry. 2011;16(4):499–516.

This older 2011 paper has in the past been cited to suggest puberty is diagnostically important for determining which children will persist in their identity. This study in fact does not demonstrate this, it instead demonstrates the following:

Social divisions: 25 people aged 14-18 reminisced about their experiences at the age of about 10, a time when social divisions between boys and girls increases in the Netherlands. 14 children who were still registered with the gender identity service in adolescence recall at that time of increased social division having wanted to be grouped with the children of the opposite gender to their assigned gender and wanting to socially transition. 11 children who had left the service before the age of 12, recall having wanted to be grouped with their assigned at birth gender and having not wished to socially transition.

View of puberty: 11 children who were in the service in childhood but left the service before the age of 12 and did not apply for puberty blockers, remember not having been distressed by the idea or the reality of pubertal changes. 14 children who were still in the service in adolescence and who applied for blockers remember being distressed at pubertal changes.

Sexual attraction: In a sample of 25 people registered at the gender clinic in childhood, when interviewed in adolesence, 14 transgender people were heterosexual, 5 cisgender girls were heterosexual and 6 cisgender boys had a variety of sexual orientations.

None of the above is evidence that puberty is diagnostically important for distinguishing between children who will or who will not need medical intervention at puberty. The study mis-cites the conclusions that can be drawn from the evidence at hand, and these mis-citations cannot still be influencing policy over a decade later when they have been called out time and again as flawed and mis-used.

[service spec page 13] “family/social circumstances that may impact on a child’s gender dysphoria”

There is no evidence that family circumstances impact on gender dysphoria, whereas there is significant evidence that family rejection impacts on poor mental health in trans children who are not affirmed.

  • 2. Omission of modern & relevant evidence on trans children’s identities.

Research by Olson (2015) and Fast (2017) shows that:

“Transgender children do indeed exist and their identity is a deeply held one.”

“Three- to 5-year-old socially transitioned transgender children did not differ from controls or siblings on gender preference, behaviour, and belief measures.”

“Transgender children aged 5-12 viewed themselves in terms of their expressed gender and showed preferences for their expressed gender, with response patterns mirroring those of two cisgender control groups.”

“These results provide evidence that, early in development, transgender youth are statistically indistinguishable from cisgender children of the same gender identity.”

(research) “findings refute the assumption that transgender children are simply confused by the questions at hand, delayed, pretending, or being oppositional. They instead show responses entirely typical and expected for children with their gender identity.”

Olson, K.; Key, A.; Eaton, N. (2015) Gender Cognition in Transgender Children Psychological Science

Fast, A & Olson, K. (2017) Gender Development in Transgender Preschool Children, Child Development

Research has shown that trans children’s may hide their identity for months or years before disclosing it to family, and hence a ‘sudden’ assertion to a parent or outsider may commonly have been long thought about by a child.

  • 3. Inclusion of outdated, mis-placed & mis-interpreted evidence on social transition

[service spec page 10] “in some cases a further consultation may be appropriate following further local assessment and intervention and or a process of watchful waiting”.

[service spec page 13] “support an exploratory approach that allows a child time and opportunity to consider different options in a flexible and non-judgemental context”.

[service spec page 14] “the clinical approach has to be mindful of the risks of an inappropriate gender transition and the difficulties that the child may experience in returning to the original gender role upon entering puberty if the gender incongruence does not persist into adolescence”

This reference to ‘difficulty returning to original gender role’ relies on one single (uncited) source which can be traced back to a letter to the editor from 2011 ((Steensma & Cohen-Kettenis, 2011) referencing the case of two Dutch children. A closer analysis reveals that neither of the two children referenced in that letter, in fact none of the children in that study, had experienced social transition according to today’s definition (Ashley, 2019a). They had non-conforming gender expression, but did not change pronoun or name, and they remained referred to as their gender assigned at birth (Steensma et al., 2011). The usage of this case, involving a small number of children who did not socially transition, to justify restrictions on supporting trans children, can be considered inappropriate, and ethically flawed (Ashley, 2019a).

Critiques of the shoddy evidence base on supposed harms of social transition are now well established and its continued use to caution against social transition is unacceptable in 2022.

This part of the NHS specification contrasts strongly with the 2017 Australian standards of care which state “The number of children in Australia who later socially transition back to their gender assigned at birth is not known, but anecdotally appears to be low, and no current evidence of harm in doing so exists”.

[service spec page 14] “for pre-pubertal children the clinical approach… will be a watchful approach overall….with a more individualised approach where the child’s level of global functioning may be maintained or improved through a carefully observed process of exploration of social transition”

[service spec page 15] “not all adolescents will want or benefit from social transition”

This sentence conflates two very different concepts.

The part on adolescents not benefitting from social transition is completely unevidenced. It also fails to consider the harms of attempting to prevent an adolescent from social transition and the control and coercion associated with such denial of self-actualisation.

‘Watchful waiting’ as a clinical approach is not supported by evidence, and is better framed as ‘delayed transition’. Significant critique is available of the harms of preventing or delaying transition (as explored further below).

[Service spec page 15] “approaches to support social transition may be considered in cases where 1) gender dysphoria is diagnosed, consistent and persistent”

Gender dysphoria does not need to be diagnosed for a social transition. Nor does it need to be consistent or persistent. This is not evidence based.

[Service spec page 15} “AND the young person…fully understands the implications of affirming a social transition (informed consent)”

A young person, particularly a young child, should not be expected to understand or predict the implications of a social transition before being affirmed in their identity. A social transition is not a medical intervention or a medical decision and inclusion of informed consent is not appropriate here. Denying a child or adolescent’s identity is a far bigger intervention and interference, than supporting a child’s identity. This is wrong and harmful. It also fails to recognise that ‘understanding implications’ is likely to focus on the risks of being trans in a transphobic world, and is likely to scare a child into trying to conform to their assigned identity. It is inherently a conversion practice.

[service spec page 15] “AND the clinical approach is necessary for the alleviation of clinically significant distress”

Whilst social transition can certainly ameliorate clinically significant distress, trans children should not experience, or demonstrate the potential of experiencing, clinically significant distress before being supporting in their identity. There also needs to be consideration of trans joy – of maintaining the potential for trans children and adolescents to have a happy childhood. Protection of trans joy, or trans normal levels of well-being are as important as preventing clinically significant distress.

[Service spec page 15] the clinical approach will involve a focus on exploring or supporting social transition through psychological support, family work/therapy…”

This fails to recognise that supported trans children living in supportive trans positive environments do not need psychological or family therapy. This needs to be stated explicitly here.

[service spec page 15] “Young people and their families will be supported in making difficult decisions regarding the expression of a gender role that is consistent with their gender identity”

This fails to consider the harms where a child suppresses their gender expression or identity. It fails to focus on the reason why it may be difficult, which is inherently life in a world where trans identities are problematised or where prejudice exists. This needs to emphasise that in this situation the difficult decision centres around building safe environments for that child to thrive in, rather than considering options where a child’s is compelled to suppress their identity.

This whole section also very much suggests a social transition is a one time event (or a mistake) rather than a step that can be taken several times, that can be itself part of exploration and self-discovery, that can be a light-hearted journey rather than a heavy and weighty diagnosis and medicalised intervention.

[service spec page 16] “Decisions about gender expression are thoughtfully considered…(even) if a young person has changed gender role prior to being seen by the service”

Why is a medicalised gender service getting involved in children’s gender expression. It does not need to be thoughtfully considered in clinical practice.

  • 4. Omission of modern & relevant evidence on social transition

Affirmative approaches advise supporting a child in their identity, prioritizing current well-being without age based barriers on acceptance (Ehrensaft et al., 2018; Temple Newhook et al., 2018b). This approach views family acceptance as critical for child self-esteem and mental health, for those children whose identity will remain constant into adulthood, as well as for those who may have a more fluid identity, including those who may go through two or more ‘social transitions’ (Ehrensaft, 2021; Keo-Meier & Ehrensaft, 2018b; Temple Newhook et al., 2018a).

A growing body of evidence supports affirmative approaches that include support for pre-pubertal social transition (Durwood et al., 2021; Olson & Gülgöz, 2018; Rae et al., 2019). Research on socially transitioned trans children has shown positive mental health and well-being outcomes, in contrast to high levels of depression, self-harm and suicidal ideation in those denied affirmation (Durwood et al., 20172021; Olson et al., 2016; Olson & Gülgöz, 2018). Research highlights the importance of family support in trans well-being, with contrasting research demonstrating the links between family rejection and suicidality, PTSD and depression (Katz-Wise et al., 2018; Klein & Golub, 2016; Pollitt et al., 2021; Russell et al., 2018; Simons et al., 2013; R. Travers et al., 2012). 

A majority of healthcare guidance published since 2015 supports pre-pubertal social transition, recommending affirmative approaches to supporting trans children, including guidance from the American Academy of Pediatrics (Rafferty et al., 2018), the Pediatric Endocrine Society Special Interest Group of Transgender Health (Lopez et al., 2017), and from national healthcare standards in Australia (Telfer et al., 2018) and New Zealand (Oliphant et al., 2018).

A study with 73 socially transitioned trans children aged 3 to 12 years found they had high levels of mental health, with levels of depression similar to cis children (Olson et al., 2016). A follow-up study on 116 socially transitioned trans children aged 6 to 14 years found high levels of mental health and self-worth in socially transitioned trans children, concluding “these findings are in striking contrast to previous work with gender-nonconforming children who had not socially transitioned, which found very high rates of depression and anxiety” (Durwood et al., 2017, p. 1).

UK based research has highlighted the benefits of social transition

Parents within this sample also evaluated the benefits of social transition, describing it as protective for their child’s happiness and well-being. Parents rejected any suggestion that supporting a pre-pubertal social transition was risky, instead emphasizing the risks of continuing to reject their child. Parents reflected upon advice for other families, emphasizing how positive it had been for their child. Parents were unanimous in recommending other parents to follow their child’s lead, affirming them in the present, perceiving this as safeguarding their child’s well-being, happiness and self-esteem.

Horton, C. (2022). “I never wanted her to feel shame”: Parent reflections on supporting a transgender child. Journal of LGBT Youth.

Other UK research has included children’s voices and perspectives on social transition

The first major theme explored experiences pretransition, with subthemes on children correcting assumptions, becoming distressed, struggling alone, reaching crisis, or growing withdrawn and frustrated. The second major theme examined experiences posttransition, with subthemes on a weight being lifted, validation at school, and well-being. This qualitative research complements existing quantitative evidence on the importance of social transition, with childhood affirmation critical to the happiness and well-being of trans children.

Horton, C. (2022). “Euphoria”: Trans children and experiences of pre-pubertal social transition. Journal of Family Relations.

  • 5. Cisnormative, pathologising, unevidenced approach to social transition being an ‘intervention’

A ‘social transition’ need not entail an end point, and may also provide an opportunity for self-understanding through, rather than just before transition (Ashley, 2019b). Bioethicist Florence Ashley (2019b, p. 6) points out that “changing names, pronouns, and undergoing transition-related interventions is routinely used by trans people in an exploratory manner, largely to positive effect.”

Ashley highlights that the categorization of ‘social transition’ as a clinical ‘intervention’ requiring justification and evidence is itself a deeply cisnormative approach; they argue that delaying or preventing a child from having their identity respected is a more active intervention in the child’s life, requiring greater evidence to justify it, than an approach that respects a child’s self-knowledge (Ashley, 2019b).

  • 6. Omission of harms of denied transition

Critics of ‘delayed transition’ argue that any potential risk of transition needs to be weighed up against the risks or harms of denying social transition (Ashley, 2021; Ehrensaft et al., 2018).

Research has shown the harms of delayed transition, with UK based research demonstrating the challenges, frustration and trauma of trans children who have experienced rejection and delay. UK research highlights that such harmful delays occur even within families who appear to be, or who have come to be affirming, with entrenched cisnormativity impeding affirmation.

“Families within this sample were unified in their positivity about supporting and affirming their child, with the only regrets spoken about being regrets at having been too slow in supporting their child. Families in this sample had experience-based insights into the negative repercussions on their child’s well-being of delay, dismissal and rejection, with every interviewee emphatic on the harms intrinsic to ‘delayed transition”. see: Horton, C. (2022). “I was losing that sense of her being happy” – Trans children and delaying social transition. LGBT+ Family Studies.

These findings also reinforce retrospective research on the negative mental health toll of childhood rejection, drawn from research with trans adults and trans youth (Ehrensaft et al., 2018; Katz-Wise et al., 2018; Priest, 2019; Turban et al., 2020; Wallace & Russell, 2013).

Further insights into the impacts of childhood rejection can be gained from retrospective research with trans adults (Kennedy, 2022; Turban et al., 2020), 

extensive literature drawing a connection between safe and affirming homes and trans youth well-being (Hill et al., 2010; Pollitt et al., 2019; Riggs et al., 2020; Russell et al., 2018).

  • 7. Fails to condemn conversion practices

explicit attempts to convert or coerce a trans child into a cis identity are condemned by mainstream health professionals (AusPATH, 2021; British Psychological Society et al., 2017; Coleman et al., 2012). Pediatric medical institutions across a number of countries have emphasized that efforts to convert trans children to a cisgender identity are both ineffective and unethical (Telfer et al., 2018). The UN Independent Expert on Protection Against Discrimination based on Sexual Orientation and Gender Identity called conversion practices “degrading, inhuman and cruel” (UN Human Rights Council, 2020, p. 21). 

A number of studies have outlined the harmful effects of conversion therapy, with the effects most pronounced on trans people who endure conversion therapy in childhood (Turban et al., 2020). Research has shown that exposure to conversion practices before the age of ten is significantly associated with severe psychological distress and lifetime suicide attempts (Turban et al., 2020). Children exposed to such practices are known to experience a severe loss of self-esteem and a sharp increase in depression, leaving them at risk of school drop-out and substance abuse (Turban et al., 2020). 

As explicit conversion therapy has moved outside of what is deemed acceptable, or in some locations legal, there remains a significant gray area, with conversion practices continuing, including from healthcare professionals, but without explicit labeling as such (Ashley, 2022). The UN report on conversion therapy underscored the harm of therapies that aim to change a child’s gender identity from trans to cis, or that hold a child being cis as preferable to a child being trans (UN Human Rights Council, 2020). The same report also emphasized that “practices aimed at changing gender identity include preventing trans young people from transitioning” (UN Human Rights Council, 2020, p. 11).

  • 8. Pathologising & incompatible with ICD-11

[service spec page 8] “research will include” “epidemiology”

[service spec page 14] “clinicians should remain open and explore…”

There is also no examination of the cisnormative bias in clinicians needing to be open and explore trans identities, when there is no such clinical exploration of cis identities.

Being transgender is now recognized by the medical establishment as a non-pathological part of human diversity, with space for trans lives to be celebrated and normalized, as a valued and important part of our families and communities (AusPATH, 2021; World Health Organisation, 2018). A medical shift away from the problematisation and pathologisation of gender diversity, has significant implications for trans children, who until relatively recently would have been diagnosed with a ‘disordered’ identity, growing up with isolation, rejection and shame (Bryant, 20062007; Gill-Peterson, 2018). 

This service specification has not grappled with the shift from ICD-10 with gender diversity pathologised, through to today’s ICD-11 where gender diversity is celebrated as part of human diversity.

Indeed the very intention of the shift to ICD-11 is to destigmatise and improve access to healthcare with the WHO stating:
In 2020, we have a better understanding of the issues surrounding this condition, and they are not related to a mental health condition.  Treating gender incongruence in a mental health chapter was causing additional stigma for an already stigmatized condition. WHO officials added the hope that adding this condition to a sexual health chapter of the ICD codes would “help increase access to care for health interventions” and “destigmatize the condition.” 


The harms of continued pathologisation and NHS responsibilities to drive forward active depathologisation are outlined in this research

Horton, C. (2022). De-pathologising diversity: Trans children and families’ experiences of pathologisation in the UK. Children and Society.

  • 9. Intrusive and inappropriate assessment

[service spec page 12] “assessment will focus on psychosexual development and any sexual experience.

Literature has evidenced the harms of such intrusive and inappropriate questioning

Horton, C. (2021) “It felt like they were trying to destabilise us”:  Parent assessment in UK Children’s Gender Services, International Journal of Transgender Health

Horton, C. (2022).“Of Course, I’m Intimidated by Them. They Could Take My Human Rights Away”: Trans Children’s Experiences with UK Gender Clinics. Bulletin of Applied Transgender Studies. 1(1-2):47-70

  • 10. Redefining EA2010 protections to remove & medicalise rights for trans children

[Equality and health Inequalities Impact Assessment section on ‘gender reassignment’]

This section is entirely unacceptable, effectively seeking to medicalise and disenfranchise trans children and adolescents through an interpretation of the protected characteristic of ‘gender reassignment’ that does not accord with the EA2010.

It suggests trans children need a diagnosis of gender dysphoria to be protected, which is not true.

It states that medical intervention is necessary to be protected, which is not true.

It even goes so far as to suggest that adolescents accessing HRT privately may not be protected under the EA2010 characteristic of gender reassignment.

Having an NHS gender service, that should be advocating for trans children and adolescent rights, instead actively seek to confuse or undermine existing rights and legal protections, is extraordinary and a dire indictment of the prejudice and poor judgement underpinning this whole service specification.

  • 11. Misapplication of ‘safeguarding’ to threaten access to life-saving healthcare

[Service spec page 12] “assessments will focus on… risk including safeguarding… including impact of any unregulated medications”

[service spec page 16]

The service needs to understand that families and adolescents looking outside of the NHS do so where the NHS has failed in its duty of care for trans youth. In my opinion, the NHS at present, and even more so in this specification, is actively harmful for trans youth. Taking steps to access essential healthcare whilst protecting trans children from the harms within the NHS model of care, is entirely appropriate. Whilst the NHS fails to provide timely depathologised healthcare, families and adolescents need to be able to access private healthcare, whilst keeping their GPs up dated.

Families with trans children, and trans adolescents already have serious trust issues with parts of the NHS. Guidance that further breaks down trust with GPs, and guidance that makes families or adolescents fear that conversations with GPs will lead to safeguarding interventions, only increases the chances of families and adolescents distancing themselves from the NHS, with consequences for wider healthcare needs.

[service spec page 18] “nor will it enter into shared care arrangements”

A blanket ban on the NHS supporting any part of healthcare sourced privately, including routine blood tests or drug administration, makes access to essential healthcare through private providers even more inaccessible, especially for families on low income. It directly prejudices against trans youth who do not have wealthy families, who will be able to access care abroad or through private provision regardless of the in-availability of shared care.  

[Equality and health Inequalities Impact Assessment section on ‘families on low income’]

Fails to consider how low income families are disproportionately impacted by failures in NHS care.

[service spec page 18] “where a young person has been prescribed hormones outside of the eligibility and readiness criteria…the service will not accept clinical responsibility…”

This means that any young person who is forced into accessing private healthcare (due to failures in NHS delivery and accessibility) will be kept out of NHS services until the age of 18. This can leave families needing to pay private healthcare costs for many years. Where family circumstances change and a family cannot continue to afford private healthcare, or where an adolescent can no longer rely on family funding, it leaves adolescents completely without access to essential medication, with no consideration of the physical and mental health risks where care is discontinued.

  • 12. Ignorant of flaws in dysphoria definitions

[service spec page 21] “appendix a diagnosis of gender dysphoria”.

The specification does not at all engage with the known deficiencies in the DSM-V diagnosis criteria.

Australia national healthcare guidance in contrast critiques the known flaws in the DSM diagnosis and makes allowances for how to provide non-stereotyped care for trans youth.

[service spec 23] “options for children who have degrees of gender incongruence but do not meet the diagnostic criteria for gender dysphoria”

Particularly the diagnosis for children is very based in stereotype, meaning that trans children who do not adhere to regressive gender stereotypes can be found sub-threshold for diagnosis, despite being trans, being socially transitioned and potentially needing access to medical intervention at puberty.

The specification notes that the DSM diagnosis will shift to the ICD-11 diagnosis, but again fails to engage with the relevance of that change in diagnostic category.  

  • 13. Ignorant of potential for harm in adding extra GP layer into referral

[service spec page 9] “referral to the service will require a consultation meeting attended by the relevant local secondary health care team and or GP”

This introduces a screening process where the child and their needs are represented by the GP. It fails to consider a huge range of problems with this model. There is significant evidence that GPs can be prejudiced, uneducated, ill-informed in this area. The small percentage of people who are at present not referred to GIDS by their GP often correspond to those who have a transphobic GP who refuses to refer to the service out of transphobic prejudice.

[service spec page 9] “outcomes following the screening process include discharge with psychoeducation”.

[service spec page 10] “in some cases a further consultation may be appropriate following further local assessment and intervention and or a process of watchful waiting”.

Giving such GPs power to represent the child’s interests in the screening discussion leaves significant room for the child to be failed in a context where GPs have no education or support on trans children. It also leaves open to yet another round of intrusive questioning of trans children – if the GP needs to represent the child in the screening process the GP will themselves need to get to know the child’s experiences, a task that many GPs are underqualified for, and a process that can be harmful to a child’s well-being and wider confidence and trust in healthcare professionals.

[service spec [page 9] “If after professional consultation between a referrer and the service a child is considered suitable for assessment, the referrer will be advised to proceed with the referral via a standardised referral form”.

This additional layer adds yet another delay in a process that is already very heavily delay-ridden. How is this in any way centring child healthcare needs or making the system more efficient and effective.

  • 14. Ignorant of harms of denial of healthcare

[service spec page 13] “implications of medical treatment (and non-treatment)”.

The second part of this statement should not be in brackets and the specification needs to much more significantly present the evidence of the harms of denial of medical treatment.

The Endocrine society, in its recommendation in support of puberty blockers, states the following:
These recommendations place a high value on avoiding an unsatisfactory physical outcome when secondary sex characteristics have become manifest and irreversible, a higher value on psychological well-being, and a lower value on avoiding potential harm from early pubertal suppression.”

  • 15. No centring of child rights to healthcare

[service spec page 8] “an individual’s route will be determined by… family and social context”

This leaves it open to trans children and adolescent’s path to healthcare being blocked by family or social context – it fails to consider child rights or how the service will centre the child and their wellbeing through the care pathway.

[service spec page 12] “the hopes and expectations of their family members/carers”

This section needs to distinguish between the need for family member support and education to help them support their child’s needs, and the potential for family members to cause harm by impeding access to healthcare.

[service spec page 14] “Medical interventions will not be considered until at least puberty…”

This feels inappropriate phrasing – a better phrasing would be to state that medical interventions are not needed in this cohort until puberty.

[service spec page 15] factors that could influence the complexity and length of the intervention include…”

Here a long list of factors that can extend assessments and delay healthcare are provided, with no consideration of child rights to care, including rights for those with mental health problems, safeguarding issues, unsupportive families, or difficulties providing consent. A child-centred approach may need to devote additional resources or effort to support children will more complex situations, but this also needs to prioritise ensuring such children are not kept in extended assessment or denied access to time-sensitive healthcare.

[Equality and health Inequalities Impact Assessment section on ‘looked after children’]

Fails to actively consider how to ensure looked after children, and those without parental advocates, are not discriminated against in healthcare access.

The specification fails to outline the necessity of trans healthcare. The Endocrine society states:
““These recommendations include evidence that treatment of gender dysphoria/incongruence is medically necessary”

  • 16. No centring of healthcare accountability or mechanisms to empower service users

Existing evidence has highlighted the potential for abuse of power and child powerlessness in clinical care

Horton, C. (2022).“Of Course, I’m Intimidated by Them. They Could Take My Human Rights Away”: Trans Children’s Experiences with UK Gender Clinics. Bulletin of Applied Transgender Studies. 1(1-2):47-70

While other research has demonstrated the flawed mechanisms for accountability in the GIDS system.

Accountability and avoidance of areas of unlimited clinician control is critical especially in an area affected by potential for clinician prejudice.

  • 17. Presentation of psychoeducation as treatment for dysphoria

[Service spec page 2] “The primary intervention…. Is psychosocial (including psychoeducation) and psychological support and intervention, the main objective is to alleviate distress associated with gender dysphoria”.

This is entirely unevidenced, can be interpreted as a form of conversion therapy, and suggests psychological support is a means of alleviating gender dysphoria. There is no emphasis here on psychological support to cope with the challenges of living in a trans hostile world, or psychological support to deal with gender minority stress, bullying, abuse or family rejection. This seems to support psychosocial support itself will change a person’s experience of gender incongruence or dysphoria and is entirely unevidenced, goes against modern healthcare best practices, and will cause direct harm to trans children and adolescents.

[service spec page 8] “research will include” “outcomes of psychological treatments to reduce distress”

There is no consideration of the place for talk therapy in helping youth deal with transphobia or gender minority stress. The phrasing is left open for conversion therapy.

[service spec [age 9] “outcomes following the screening process include discharge with psychoeducation”.

This needs to justify why a child or adolescent who has wanted and needed referral to the service would be discharged with psychoeducation. It fails to consider who the psychoeducation is for, what its purpose is. It strongly leaves the specification open to an interpretation that the screening can identify who is ‘really trans’ and who can be assigned psychoeducation to reconcile with their assigned gender. It leaves space for conversion practices that are unacceptable in modern healthcare.  

[service spec page 14] “psychological support will focus on alleviating emotional problems” “The overall aim is to reduce distress in the individual”

This approach leaves open the interpretation that psychological support is an effective treatment for gender dysphoria, rather than psychological support to deal with gender minority stress.

In contrast, the endocrine society states that the purpose of counselling linked to social transition is to help manage other people’s reactions:

“During social transitioning, the person’s feelings about the social transformation (including coping with the responses of others) is a major focus of the counseling.”

  • 18. No emphasis on psycho education to raise trans positivity

[service spec page 13] “psychoeducation”

The section on psychoeducation focuses on gender identity development, not on the very important topic of raising trans positivity.

Other literature has highlighted the importance of education on trans identities and trans positivity, especially for cis parents.

Horton, C. (2021) “It felt like they were trying to destabilise us”:  Parent assessment in UK Children’s Gender Services, International Journal of Transgender Health

  • 19. No centring disability & neurodiversity rights

[service spec page 8] “an individual’s route will be determined by… the presence and impact of other clinical needs”

This leaves it open to trans children and adolescent’s path to healthcare being blocked or disadvantaged if they are disabled or neurodivergent – it fails to consider disability and neurodiversity rights or how the service will centre the child and their wellbeing through the care pathway, making sure disabled youth are not discriminated against.

[service spec page 12] “assessments will focus on …neurodevelopmental needs and their relationship with gender incongruence”

Neurodivergent trans children should not need to explain or define the relationship between neurodiversity and gender incongruence.

[service spec page 15] “more intensive clinical interventions may be needed…to address other clinical diagnoses”

The service is not committing to upholding the rights of disabled trans youth, including disabled or mentally ill trans youth.

[Equality and health Inequalities Impact Assessment section on ‘disability’]

Fails to consider the reality that disabled children are likely to be discriminated against with greater barriers to timely healthcare. Fails to put in place strategies to ensure those with disabilities, co-existing mental health conditions and neurodiversity are not discriminated against in access to timely healthcare.

  • 20. Failure to recognise gender minority stress as key driver of mental health differentials

[Service spec page 2] “experience co-existing mental health… and or family or social complexities in their lives”.

[service spec page 11] “increased prevalence of mental health needs such as depression anxiety risk-taking behaviours”

This section entirely fails to deal with the significant body of evidence that demonstrates that mental health issues, or family and social issues are highly likely to not be co-existing, but directly caused by societal prejudice and gender minority stress. The stress of living in a trans hostile society places a significant burden on trans children and this service specification needs to recognise that in many cases mental health differentials and family/social difficulties are not caused by gender incongruence, but by societal, community, peer and family responses to that gender incongruence. It is absolutely vital to recognise that the ‘problem’ is not internal to the child, but one of the reaction to the child. This places a very significant emphasis on the need to undertake responses at family, community and society level, not at the level of the child.

These references to co-existing conditions also fail to recognise that denial of essential healthcare is a known driver of such mental health difficulties.

[service spec page 12] “assessments will focus on… impact of gender incongruence on educational attainment, bullying or harassment”.

This needs to clearly distinguish that it is not gender incongruence that has this impact, but societal prejudice.

[service spec page 14] “The overall aim is to reduce distress in the individual”

Fails to understand that solutions to tackle GMS should not focus on the individual but on the surrounding environment.

Trans children and adolescents are known to be at risk of poor mental health, with a wide variety of studies noting high levels of depression, anxiety or suicidal ideation (Srivastava et al., 2020; Strauss et al., 2020; Veale et al., 2017). A growing body of research has also shown that poor mental health is not intrinsic to being trans, with evidence demonstrating a wide range of external factors that correlate with good mental health, including family support (Katz-Wise et al., 2018; Klein & Golub, 2016; Pullen Sansfaçon et al., 2019; Simons et al., 2013; Travers et al., 2012), social affirmation (Durwood et al., 2017; Olson et al., 2016; Whyatt-Sames, 2017), and safe and welcoming trans-inclusive primary and secondary education (Horton, 2020; McGuire et al., 2010).

Trans children’s experiences of Gender Minority Stress in education in the UK are evidenced here:

Horton, C. (2022). Reducing Gender Minority Stress – Support for trans pupils in our schools. International Journal of Transgender Health.

  • 21. Suggests intrusive search for causation

[Service spec page 2} “the relationship between these aspects (mental health, neuro-developmental and or family or social complexities) and gender incongruence may not be readily apparent and will often require careful exploration”.

This phrasing leaves itself open to the interpretation that gender incongruence may be ‘caused’ by family disfunction, mental health issues or neurodiversity, suggesting that such causes ‘often’ need to be ‘carefully explored’. This is an outdated approach that has been tried for many decades and found to be harmful and abusive. Existing research shows that trans children and families find such ‘exploration’ intrusive, harmful and irrelevant.

[Service spec page 5] “build and document the history and nature of gender incongruence”.

It is striking that despite citing the Endocrine society elsewhere in this specification, it does not mention a key conclusion of the Endocrine society that gender identity has a “durable biological underpinning”

Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline,” Journal of Clinical Endocrinology & Metabolism (JCEM), Nov 2011.

The Endocrine society position paper states:

The medical consensus in the late 20th century was that transgender and gender incongruent individuals suffered a mental health disorder termed “gender identity disorder.” Gender identity was considered malleable and subject to external influences. Today, however, this attitude is no longer considered valid. Considerable scientific evidence has emerged demonstrating a durable biological element underlying gender identity. Individuals may make choices due to other factors in their lives, but there do not seem to be external forces that genuinely cause individuals to change gender identity.

Although the specific mechanisms guiding the biological underpinnings of gender identity are not entirely understood, there is evolving consensus that being transgender is not a mental health disorder. 


[service spec page 8] “a care plan should be tailored…following careful therapeutic exploration”.

The fact a care plan can only come after careful therapeutic exploration suggests this is mandatory, and that it is therefore neither therapeutic nor exploratory. Therapeutic exploration is client driven not clinician driven. Mandatory exploration is something quite different, and instead is an intrusive and abusive exercise in clinician power over a trans youth. This approach fails to consider the power wielded by clinicians (some of whom hold transphobic prejudices), and the need to centre trans children’s right to not engage in forced exploration before having access to a care plan. It is a one-size fits all approach that fails to recognise that many trans children have no need of, and will be harmed more than helped by therapeutic exploration, and that mandated exploration is neither therapeutic nor exploratory. To the contrary, there is evidence that mandated exploration can put trans youth into a position of defending their identity, reducing space for genuine exploration, and leading to worse outcomes.

Furthermore, work by Ashley has demonstrated that self-guided reflection and exploration is a process that should take place through the process of wider healthcare, not as a step before access to a care plan.   

  • 22. Leaves space for gender exploratory therapy

[service spec page 14] “clinicians should remain open and explore…”

Gender exploratory therapy is a rebranded label for conversion therapy, and the service specification, with numerous references to exploration retains space for this harmful practice.

  • 23. Uses dated and unscientific language for ideological purposes to illegitimise and disenfranchise

[service spec page 3] “biological sex”.

In this section the NHS has redefined the diagnosis of gender incongruence to include the inaccurate term of “biological sex”

The WHO ICD-11 instead defines gender incongruence thus:

“Gender incongruence is characterized by a marked and persistent incongruence between an individual´s experienced gender and the assigned sex”.

The NHS has rewritten the WHO’s definition to include inaccurate and transphobic language of ‘biological sex’ rather than ‘assigned sex’ with this change likely to delegitimise and disenfranchise.

[Service spec page 6] “biological sex”

In this section the NHS propose the whole system’s outcome monitoring system records by ‘biological sex’, with this inaccurate and harmful categorisation likely to other, delegitimise, insult and harm trans children and young people. Such monitoring is also likely to lead to service users refusing to participate in data gathering – services need to maintain service user trust and confidence for any effective collaboration including in basic data gathering. Having a monitoring system that is designed to monitor by “biological sex” is cisnormative and harmful – every monitoring report will misgender and harm its service users. This is unacceptable.

The Endocrine society (who are the only citation in this specification) specifically advise against use of the phrase “biological sex”. They state that “the terms biological sex and biological male or female are imprecise and should be avoided.”

The phrase biological sex rather than sex assigned at birth is an ideological inclusion in this document, with potential to illegitimse and disenfranchise trans people, especially given existing political discourse around ‘sex’ and ‘single-sex spaces’. This phrase should be nowhere near a document purporting to serve and support trans children and young people. It is a direct microaggression, serving to signify to readers that the service is not designed in their interests.

[Equality and health Inequalities Impact Assessment section on ‘sex’]

This section misgenders and delegitimises trans children and adolescents, ascribing them as ‘natal males’ and ‘natal females’. This is unacceptable language in a specification supposed to help trans children.

  • 24. Emphasis on MDT

[Service spec page 8] “the provider will deliver the Service through an integrated MDT”

There is no consensus on what an MDT for trans youth healthcare looks like, and within the Helen Webberley GMC proceedings, expert witnesses (leading clinicians from the US) gave extensive testimony on the inappropriateness of an MDT for trans youth healthcare. The NHS needs to take this expert testimony on MDTs into account here.

  • 25. Failure to centre endocrine care pathways

Being trans is not a medical condition. This is clearly established under ICD-11. Trans children and adolescents mainly need to have specialist healthcare support when they require endocrine interventions. Having a specialist gender care pathway that barely engages with a focus on endocrine care, is deeply regressive and fails to recognise that for many trans children, endocrine care is the sole reason for engaging in trans healthcare. Support with gender minority stress could be found outside of tertiary trans healthcare care, support for families can be found through more informal structures, and support for social transition often does not require and would even be harmed by incorporation into specialist healthcare.

  • 26. Failure to engage with trans expertise

The draft specification is unbelievably bad. This is what happens when healthcare is ideologically influenced, and when trans expertise is explicitly excluded. The NHS needs to do so much better. Trans kids deserve evidence-based trans-positive healthcare.

27. Under-planning for given population

I noticed in the spec that they mention lower referrals for 2020-1 without contextualising the referral numbers were artificially low because of the pandemic.

I also noticed that in their consideration of referral numbers they entirely fail to consider the trans youth who have not bothered to get an NHS referral recently because they know the wait list is 4+ years – those who have had to go private or who have waited for adult services (knowing GIDS won’t help them before adulthood anyway) are entirely unconsidered in the specification’s analysis of the size of the population the new service will cover.

Steph’s place did some further important analysis of the under-planning for the population in their blog:

Additional important critique of the service spec is in this blog

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