The BBC broke a story July 28 headlined, “NHS to close Tavistock child gender identity clinic.” Following the Cass Interim Review determination that the current model of care “is not a safe or viable long-term option,” Britain’s National Health Service announced that their Gender Identity Development Service (GIDS), the world’s largest pediatric gender clinic, is to close by spring 2023. It is to be replaced with centers in London and North West with increased emphasis on mental healthcare and relevant general practitioner services.  Also noted was that the UK’s 20-fold increase in referrals over the last decade (250 then and 5,000 in 2021) had overwhelmed the capacity of the service.

The Cass Review Interim Report is an extensive and revealing document, even as a work in progress. Some relevant quotes from the review stand out. From page 17, para. 1.14, “Primary and secondary care staff have told us that they feel under pressure to adopt an unquestioning affirmative approach and that this is at odds with the standard process of clinical assessment and diagnosis that they have been trained to undertake in all other clinical encounters.” In 2019, news.sky.com reported that 35 psychologists resigned from NHS’s GIDS over three years, complaining of over-prescribing the medicalization of gender dysphoric minors “with psychologists unable to properly assess patients over fears they will be branded ‘transphobic…’,” alarmingly adding, “we fear that we have had front row seats to a medical scandal.”

Here are but some of the related quotes from the Cass Review supporting the complaints of the above referenced psychologists:

• Page 17, para. 1.15, regarding “diagnostic overshadowing – many of the children and young people presenting have complex needs, but once they are identified as having gender-related distress, other important healthcare issues that would normally be managed by local services can sometimes be overlooked.”
• Page 17, para. 1.18, “From the point of entry to GIDS 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.” “There is limited evidence of mental health or neurodevelopmental assessments being routinely documented, or of a discipline of formal diagnostic or psychological formulation.”

The “existing evidence base” section of the review calls out the deficiencies in gender affirming therapy as a whole:

• Page 18: “Evidence on the appropriate management of children and young people with gender incongruence and dysphoria is inconclusive both nationally and internationally.”
• Page 19, para. 1.25. “There has not been routine and consistent data collection within GIDS, which means it is not possible to accurately track the outcomes and pathways that children and young people take through the service.”
• Page 19, para. 1.26. “Internationally as well as nationally, longer-term follow-up data on children and young people who have been seen by gender identity services is limited, including for those who have received physical interventions; who were transferred to adult services and/or accessed private services; or who desisted, experienced regret or detransitioned.”
• Page 19, para. 1.27. “There has been research on the short-term mental health outcomes and physical side effects of puberty blockers for this cohort, but very limited research on the sexual, cognitive or broader developmental outcomes.”

And from the now oft-cited conclusions of the Cass Review’s “service model” section (page 20):

• “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.”
• “A fundamentally different service model is needed which is more in line with other paediatric provision, to provide timely and appropriate care for children and young people needing support around their gender identity. This must include support for any other clinical presentations that they may have.”

The NHS decision to close its GIDS, pending the arrival of a new model in 2023, comes after considerable criticism.

• The Royal College of General Practitioners’ 2019 position statement sounded the alarm on the unproven nature of gender-affirming therapy (GAT) and its transition emphasis.

• BMJ editor in chief Carl Heneghan wrote in May 2019, “The current evidence does not support informed decision making and safe practice in children.”
• A 2019 article by Richards C, et al., carried the clever title, “Use of puberty blockers for gender dysphoria: a momentous step in the dark.”
• Oxford Professor Michael Biggs published critiques of NHS GIDS having produced only a single study (at that time) from their trial of puberty blockers, which showed “no statistically significant difference in psychosocial functioning between the group given blockers and the group given only psychological support.” He also found unpublished evidence showing puberty blockers “exacerbated gender dysphoria.”

• The UK’s National Institute for Health and Care Excellence (N.I.C.E.) issued reviews in 2020 on puberty blockers and cross-sex hormones.
  • “Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria.”:
    • Conclusion: “The results of the studies that reported impact on the critical outcomes of gender dysphoria and mental health (depression, anger and anxiety), and the important outcomes of body image and psychosocial impact (global and psychosocial functioning), in children and adolescents with gender dysphoria are of very low certainty using modified GRADE. They suggest little change with GnRH analogues from baseline to follow-up.”
  • “Evidence review: Gender-affirming hormones for children and adolescents with gender dysphoria.”:
    • Conclusion: “Results from 5 uncontrolled, observational studies suggest that, in children and adolescents with gender dysphoria, gender-affirming hormones are likely to improve symptoms of gender dysphoria, and may also improve depression, anxiety, quality of life, suicidality, and psychosocial functioning. The impact of treatment on body image is unclear. All results were of very low certainty using modified GRADE.”
    • Very significantly: “Adverse events and discontinuation rates associated with gender-affirming hormones were only reported in 1 study, and no conclusions can be made on these outcomes.”
• Though overturned in Appeals Court, the UK High Court case ruling in Bell vs. Tavistock on December 12, 2020 ruled that puberty blockers and cross-sex hormones constitute experimental treatments with limited evidence for efficacy and safety which cannot, in most cases, be given to children under 16 years of age without application to the court. It suggested similar caution for minors under aged 16 and 17. The court deftly asserted, “There is no age appropriate way to explain to many of these children what losing their fertility or full sexual function may mean to them in later years.” The litigation continues.
• That same December 2020, the NHS issued amendments to service specifications for Gender Identity Development Service (GIDS) for children and adolescents reflecting the Bell vs. Tavistock decision.

While British medical, legislative and judicial agencies work over the issue of what therapy for pediatric gender dysphoria should look like, another cultural factor is coming into play: medical malpractice suits. The Times ran a story this month titled, “Tavistock gender clinic ‘to be sued by 1,000 families,’” and the Daily Mail published another (without paywall). The same will occur in the U.S., but for now the Brits are leading the charge away from gender-affirming therapy in minors.