Interim service specification for specialist gender dysphoria services for children and young people – Public Consultation

 The NHS are consulting the public on provision of interim services for young peopleexperiencing gender dysphoria – to make a submission go here – 

https://www.engage.england.nhs.uk/specialised-commissioning/gender-dysphoria-services/

Questions are multiple choice as follows –

Agree /Partially Agree /Neither Agree nor Disagree /Partially Disagree /Disagree  – with the option to make further comment. LWD’s answers and further comments are shown below.

Please feel free to use and adapt these for your own submission. The deadline is Sunday 4.12.22

QUESTIONS

1. Are you responding on behalf of an organisation?

(Required) Yes No

LWD response – yes

If yes, please tell us which organisation you are responding on behalf of:

Labour Women’s Declaration working group

2. In what capacity are you responding?

(Required) Patient Parent Clinician Service provider Other (please describe below)

Policy campaigning group

3. To what extent do you agree with the four substantive changes to the service specification listed in the supporting documents?

Composition of the clinical team

LWD’s response – AGREE

Share any further comments about this:

The inclusion of specialists in paediatric medicine, autism, neurodisability and mental health in a wide multi-disciplinary team is very much to be welcomed.  There is, however, some concern about the availability of adequate numbers of psychologists and psychotherapists with the training to provide the necessary long-term support for many of these children and young people.  Additionally, the Memorandum of Understanding on Conversion Therapy (MoU), to which most psychology and psychotherapy trainings and registers are signed-up, may be skewing the approach of many of these professionals.  Indeed, NHS England itself is a signatory (as are NHS Scotland and NHS Wales), which makes for a serious conflict with the principles outlined in these specifications.  It would be appropriate for NHS England to withdraw from the MoU; to establish clear guidelines and ensure that those working for the new services know that they are expected to provide neutral exploratory psychotherapy/clinical psychology assessments and work, and not to ‘affirm’ as a matter of course.  Specialist training courses will need to be expanded and free of the ideology inherent in the MoU. 

It is obviously essential that all members of the team, and the local services with which they will liaise, understand such issues as adolescent confusion/concern about sexual orientation (and the possibility of latching on to the notion of ‘gender dysphoria’ or ‘being trans’ to escape this); the matters raised by detransitioners concerning the ways in which mental health difficulties, trauma and peer pressure relating to social awkwardness (including from autism spectrum difficulties), or same-sex attraction, led them to the notion of gender dysphoria and transition.

Clinical leadership

LWD’s response – PARTIALLY DISAGREE

Share any further comments about this:

Medical doctors cover a wide range of specialisms, but it should be made clear that medical interventions are not assumed as a likely outcome, which is somewhat implied by the wording.  The importance of identification of so-called ‘co-morbidities’ early in the assessment process, and appropriate referral to specialist child psychotherapy and autism spectrum services, means that an understanding of the primacy of addressing such matters, before any narrow focus on gender concerns, must be embedded across the service.  This requires leadership which recognises and emphasises the importance of psychological and social context understandings.

Collaboration with referrers and local services

LWD’s response – AGREE

Share any further comments about this:

We are glad to see a presumption of care as close to home as possible, using appropriate available professional personnel.  The intention of providing full support and consultation to the local services is absolutely what is needed, but it must be recognised that many of these services have, for the last decade and more, been heavily influenced by the notion of ‘affirmation’ as an expected to a child/young person claiming gender dysphoria.  Therefore it is essential to enable a wide range of professionals working in local services to understand the nature of the changed approach.

Referral sources

LWD’s response – AGREE

Share any further comments about this:

It is clearly appropriate that children and young people should have engaged with their local services before a referral on to the specialist multi-disciplinary centres is contemplated.  Referral by schools, social services and others was never appropriate.

4. To what extent do you agree that the interim service specification provides sufficient clarity about approaches towards social transition?

LWD’s response -AGREE

Please expand further:

We are pleased and relieved to see the recognition of the fact that social transition is an intervention with serious implications, which can disrupt what might otherwise be the resolution, through adolescence, of a sense of incongruence.  It is of course crucial that all the practitioners involved in the child/young person’s care, along with parents and teachers, work together to support, and not accede to demands for social transition by, the child/young person.  This will entail ensuring that all parties fully understand the lack of evidential support for such an approach, the high probability that any gender dysphoria or discomfort with the sexed body will resolve in the course of adolescence.  It is particularly important that schools are clear that the impact of such social transition, on the young person, their peers, and their parents, can have considerable adverse effects both immediately and in the long term. 

5. To what extent do you agree with the approach to the management of patients accessing prescriptions from un-regulated sources?

LWD’s response – AGREE

Please expand further:

It is very welcome that un-regulated sources will not be able to be used to access further NHS services.  The clear importance of full multi-disciplinary and carefully-considered care and treatment is well-promoted through this approach, and will hopefully discourage parents and young people from accessing such prescriptions with all their attendant dangers. 

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?

We are concerned about the use of ideological language, such as ‘birth-assigned sex’ and ‘natal female/male’, the use of the term ‘gender’ without definition, and an apparent acceptance of the concept of ‘gender identity’, a vague self-reported personal description.  This stands in contrast to the general, and welcome, neutrality of language and approach, and we suggest these issues should be addressed in order to ensure that there is no misunderstanding. 

While the division of children’s services and adult services at the age of 18 has been traditionally used throughout the health service, we feel strongly that those between 18 and 25 (the average age at which brain maturity is achieved) do need a transitional service that will be based in the principles expressed in this interim service specification.  We hope that this is being considered for the forthcoming service specification.  

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?

LWD’s response – PARTIALLY AGREE

Please expand further:

While the very high proportion of those presenting with autism, ASD and mental health comorbidities is stated, we are concerned that the process for initial assessment does not address these issues sufficiently.  It is clear that, for many children and young people, these other issues are the real problem, and they have come to believe that their ‘gender identity’ is the cause of social and other difficulties that they experience.  It is absolutely essential that all the intake, both those already within the GIDS cohort and the new referrals, are ensured of a detailed, comprehensive, assessment and ongoing psychotherapy to address such issues before any specific gender-related focus. 

There is a serious unaddressed inequality – that of geographical residence.  While we recognise that this is an NHS England specification, as part of the United Kingdom it must be of concern that children and young people in Scotland are being subjected to an extreme version of the GIDS approach that the Cass Review has found wanting.  While NHS England cannot determine Scottish or Welsh policies, it is clearly important that full discussions with these services take place, at least to avoid cross-border issues arising from the very different provision at the Sandyford Clinic in Scotland. 

Additionally, there is no provision in the interim service specification for those children and young people resident in Wales, who have previously been referred to the GIDS at the Tavistock and Portman Clinic.  No similar appropriate NHS service is currently available in Wales, so far as can be ascertained.  These children and young people are therefore liable to be left without a service.