Local NHS leaders should pause offering first appointments at adult gender clinics to under-18s, NHS England has said following the Cass Review.
In its response to the independent review into gender identity services by Dr Hillary Cass, published 10 April, NHS England said it will set out a full implementation plan ‘in due course’. But added that it had already written a letter to local NHS leaders asking for a pause in appointments for those under 18.
The review set out 32 recommendations (see box) on gender identity services, setting out a ‘different approach to healthcare, more closely aligned with usual NHS clinical practice that considers the young person holistically and not solely in terms of their gender-related distress’.
These recommendations included the need for caution in the initiation of medical interventions for those under 18 years of age.
In a letter responding to Dr Cass, John Stewart, national director of specialised commissioning at NHS England and Professor James Palmer, medical director of specialised commissioning at NHS England, said they had written to NHS leaders to instruct them to pause offering first appointments to people before they turned 18.
They said: ‘In view of your advice about the need for caution in the initiation of medical interventions for young people under 18 years of age, our letter instructs the adult gender clinics to implement a pause on offering first appointments to young people below their 18th birthday.’
An NHS spokesperson added: ‘We will set out a full implementation plan following careful consideration of this final report and its recommendations, and the NHS is also bringing forward its systemic review of adult gender services and has written to local NHS leaders to ask them to pause offering first appointments at adult gender clinics to young people below their 18th birthday.’
NHS England added that it will ‘strengthen the description of infrastructure’ within the final version of the service specification for gender services, which it will ‘look to develop’. Currently, there is an interim specification.
It said it ‘expects’ to launch a public consultation in 2024/25 on any revisions, and to provide ICBs with ‘the guidance and support they will need to build the local services’.
The response said: ‘The clinical approach set out in our published interim service specification remains consistent with the findings and recommendations of your review and we will continue to apply this as we look to bring on board additional regional centres.
‘As we look to develop a final version of this service specification, we will particularly strengthen the description of the infrastructure that will be needed for the new services to operate within regional networks to ensure the specialist regional centres are connected with a matrix of local secondary care paediatric services, children and young people’s mental health services, primary care, and school nursing.
‘We would expect to launch a public consultation on any revisions to the service specification during the course of 24/25 and to provide Integrated Care Boards with the guidance and support they will need to build the local services.’
Overview of recommendations from the Cass Review
- Services must operate to the same standards as other services seeing children and young people with complex presentations and/or additional risk factors.
- Expand capacity through a distributed service model, based in paediatric services and with stronger links between secondary and specialist services.
- Children/ young people referred to NHS gender services must receive a holistic assessment of their needs to inform an individualised care plan. This should include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment.
- Standard evidence based psychological and psychopharmacological treatment approaches should be used to support the management of the associated distress from gender incongruence and cooccurring conditions, including support for parents/carers and siblings as appropriate.
- Services should establish a separate pathway for pre-pubertal children and their families. ensuring that they are prioritised for early discussion about how parents can best support their child in a balanced and non-judgemental way. When families/carers are making decisions about social transition of pre-pubertal children, services should ensure that they can be seen as early as possible by a clinical professional with relevant experience.
- NHS England should ensure that each regional centre has a follow-through service for 17–25-year-olds; either by extending the range of the regional children and young people’s service or through linked services, to ensure continuity of care and support at a potentially vulnerable stage in their journey. This will also allow clinical, and research follow up data to be collected.
- There needs to be provision for people considering detransition, recognising that they may not wish to re-engage with the services whose care they were previously under.
- A full programme of research should be established to look at the characteristics, interventions and outcomes of every young person presenting to the NHS gender services.
- The puberty blocker trial previously announced by NHS England should be part of a programme of research which also evaluates outcomes of psychosocial interventions and masculinising/ feminising hormones.
- The option to provide masculinising/feminising hormones from age 16 is available, but the Review recommends extreme caution. There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18. Every case considered for medical treatment should be discussed at a national Multi- Disciplinary Team (MDT).
- Implications of private healthcare on any future requests to the NHS for treatment, monitoring and/or involvement in research, and the dispensing responsibilities of pharmacists of private prescriptions needs to be clearly communicated.
Source: Cass review
