‘Adversarial’ adult trans debate is hindering teenagers, report finds

The “adversarial” debate about adult transgender issues is hindering the development of a care model for teenagers with gender dysphoria, according to a UK review group.

The group, which is headed by Dr Hilary Cass, is conducting an independent review of the UK's gender identity service for children and young people and has recently recommended a more diverse, regional provision of the service.

Currently, the Tavistock and Portman NHS Foundation Trust is the sole clinic providing specialist assessments of children and young people in the UK suffering from stress because of issues to do with gender identity.

The clinic assesses the children and young people as to whether they should be treated by way of puberty blockers and cross-sex hormone treatments. "It has become increasingly clear that a single specialist provider model is not a safe or viable long-term option in view of concerns about lack of peer review and the ability to respond to the increasing demand," the review group said in an interim report published earlier this month.

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The Tavistock clinic, which has been the subject of controversy in recent years, has, up to 2020, been providing an assessment service for Irish children and young people suffering from gender dysphoria. The HSE is now moving to develop a model provided by the domestic health service, though a recent attempt to hire a psychiatrist to head the service for Irish children and young people was not successful.

In both the UK and Ireland, the significant rise in demand for a gender service for children and young people with gender dysphoria has led to long waiting lists, causing additional stress for the young people involved and their families.

Mostly, the young people with gender dysphoria do not see themselves as having a medical condition and are anxious to start hormone treatment as soon as possible, the Cass report noted. “There is often a sense of frustration with what several describe as the ‘gatekeeping’ medical model,” it said.

However, the provision of clinical care in this area should involve the same ethical, scientific and professional standards as other forms of clinical care, according to the report. It said professionals have adopted different clinical approaches depending on their views on the cause of gender dysphoria in children and young people.

‘Affirmative approach’

Once children and young people get access to the Tavistock clinic, “there appears to be predominantly an affirmative, non-exploratory approach, often driven by child and parent expectations and the extent of social transition that has developed due to the delay in service provision”. The review group said it had been told that “many individuals [staff] who are more cautious and advocate the need for an exploratory approach have left the [clinic]”.

As well as being affected by the polarity of the debate about transgender issues, the development of a care model for children and young people is also affected by the lack of data on which to ground evidence-based assessments as to the best clinical approach, the report said.

Much of the available data concerns natal males who develop gender incongruence at a very early age, whereas the surge in recent years in children and young people suffering gender dysphoria has seen a marked increase in natal females who become distressed in their teenage years. “Approximately one third of children and young people referred to [Tavistock] have autism or other types of neurodiversity,” the report also noted. There is also an over-representation of “looked after” children – young people who have been cared for outside the family home – seeking treatment, the report said.

“It is highly unlikely that a single cause for gender incongruence will be found,” the group said, and many of those who have studied the issue “view gender expression as a result of a complex interaction between biological, cultural, social and psychological factors”.

The polarised views among patients, parents, clinical staff, and the wider public about how gender incongruence in children and young people should be interpreted is affecting views on clinical management. A lack of a conceptual agreement about the meaning of gender dysphoria is also hampering research, the report said.

The review group said that, as with many other contemporary polarised disagreements, the situation is exacerbated when no space is given for “open, non-judgmental discussions” about differing perspectives.

In its report, the group directly addressed the young patients with gender dysphoria, stressing its commitment to more and better treatment. However, it said this may take time.

Puberty blockers

It said it was not in a position as yet to give a view as to the administration of puberty blockers to children and young people, but said clinical notes should show clearly what information has been provided to the patients and their parents/guardians as to “likely outcomes and side effects of all hormone treatment, as well as uncertainties about longer-term outcomes”.

A multi-professional review group that has been put in place by the NHS should continue to review all patients being referred for hormone services by the Tavistock Clinic, the report said.

The “rapid increase” in the number of later-presenting teenage natal females only began around 2014, the group noted. “Since young people may not reach a settled gender expression until their mid-20s, it is too early to assess the longer-term outcomes of this group.”

The review group is continuing its work and a final report is to be published at a later date.