National Health Service ends “gender-affirming care,” replaces with “holistic and appropriate” care

October 25, 2022 • 9:45 am

The NHS has come to its senses and issued a whole new set of protocols for treating gender dysphoric youth. Previously, the Tavistock Clinic in London was the go-to place for these children, whose numbers have risen rapidly in the past few years, especially for females (graph below from here):

But there were complaints from patients, and a commissioned report on the Clinic by Dr. Hilary Cass damned the form of care practiced at Tavistock: “affirmative care,” which in practice meant affirming a child’s wishes about changing sex, which led to buttressing their wishes by giving puberty blockers to prepubescent youth, and ultimately adding hormone therapy and referring children for surgery to remove breasts and remodel genitals (the NHS never covered gender-transition surgery).

The problem was that many youth with gender dysphoria have mental problems or are simply distressed about their sexuality, and that lots of these difficulties resolve themselves without changing gender—often by becoming gay, which involves no drugs or surgery.

It was this rush to judgment and treatment, combined with a spate of pending lawsuits by former patients, that led to Tavistock’s downfall. Its functions will not only be farmed out to other centers, but the whole notion of “affirmative care” is being abandoned in favor of what I see as more sensible approach, which the article below calls “a holistic view of identity development in children and adolescents. Preliminary assessment will include “nonaffirmative” but supportive therapists, and there will be no “rush to hormones”;  puberty blockers (whose long-term effects are still largely unknown)  and hormones like testosterone administered only in clinical trials. The whole National Health Service protocol has been revised, and those who evade it by, say, ordering their own hormones, will not be further supported by the NHS.

These changes, following protocols already implemented in Sweden and Finland, are described in the article below from the Society for Evidence Based Gender Medicine (click to read):


Here’s what the article says about why the Tavistock protocols were abandoned.

The reasons for the restructuring of gender services for minors in England are 4-fold. They include (1) a significant and sharp rise in referrals; (2) poorly-understood marked changes in the types of patients referred; (3) scarce and inconclusive evidence to support clinical decision-making, and (4) operational failures of the single gender clinic model, as evidenced by long wait times for initial assessment, and overall concern with the clinical approach.

And a bit about the new program:

The new NHS guidance recognizes social transition as a form of psychosocial intervention and not a neutral act, as it may have significant effects on psychological functioning. The NHS strongly discourages social transition in children, and clarifies that social transition in adolescents should only be pursued in order to alleviate or prevent clinically-significant distress or significant impairment in social functioning, and following an explicit informed consent process. . . 

The new NHS guidelines represent a repudiation of the past decade’s approach to management of gender dysphoric minors.  The “gender-affirming” approach, endorsed by WPATH and characterized by the conceptualization of gender-dysphoric minors as “transgender children” has been replaced with a holistic view of identity development in children and adolescents. In addition, there is a new recognition that many gender-dysphoric adolescents suffer from mental illness and neurocognitive difficulties, which make it hard to predict the course of their gender identity development.

“Social transition” comprises the acts of medical professionals facing children with gender with gender dysphoria and helping them change gender with puberty blockers and hormones.

There are ten highlights (i.e., changes from the Tavistock protocols) in the NHS’s new system. They’re described in the article, and I’ll put them below with one or two aspects of each intervention (there are more in the article). All extracts from the article are indented; my own comments are flush left.

1. Eliminates the “gender clinic” model of care and does away with “affirmation”

  • “Affirmation” has been largely eliminated from the language and the approach. What remains is the guidance to ensure that “assessments should be respectful of the experience of the child or young person and be developmentally informed.”

  • Medical transition services will only be available through a centralized specialty Service, established for higher-risk cases. However, not all referred cases to the Service will be accepted, and not all accepted cases will be cleared for medical transition.

2. Classifies social gender transition as an active intervention eligible for informed consent

  • The NHS is strongly discouraging social gender transition in prepubertal children.

They outline the criteria needed to address gender transition, which include “persistent and consistent gender dysphoria” and “a clear and full understanding of the implications of social transition.”

3. Establishes psychotherapy and psychoeducation as the first and primary line of treatment

  • All gender dysphoric youth will first be treated with developmentally-informed psychotherapy and psychoeducation by their local treatment teams.

This is one of the main ways the Tavistock model failed: it didn’t use therapists who would assess the patient objectively rather than push them into changing genders.

4. Sharply curbs medical interventions and confines puberty blockers to research-only settings

  • The NHS guidance states that the risks of puberty blockers are unknown and that they can only be administered in formal research settings. The eligibility for research settings is yet to be articulated.

  • The NHS guidance leaves open that similar limitations will be imposed on cross-sex hormones due to uncertainty surrounding their use, but makes no immediate statements about restriction in cross-sex hormones use outside of formal research protocols.

This is an important change because the long-term effects of puberty blockers, especially used in combination with hormones like estrogen or testosterone, are not known.

5. Establishes new research protocols

  • All children and young people being considered for hormone treatment will be prospectively enrolled into a research study.

  • The goal of the research study to learn more about the effects of hormonal interventions, and to make a major international contribution of the evidence based in this area of medicine.

These studies will be continued into adulthood, as they should be. It’s important to know whether there are delayed injurious effects of hormones, as well as psychological “desisting”, or regret for changing gender.

6. Reinstates the importance of “biological sex”

  • The NHS guidance defines “gender incongruence” as a misalignment between the individual’s experience of their gender identity and their biological sex.

This change and the others implicitly assume that there is such a thing as biological sex and that it’s not a social construct. They don’t say there are only two biological sexes, but I think that’s assumed.

7. Reaffirms the preeminence of the DSM-5 diagnosis of “gender dysphoria” for treatment decisions

  • The NHS guidance differentiates between the ICD-11 diagnosis of “gender incongruence,” which is not necessarily associated with distress, and the DSM-5 diagnosis of “gender dysphoria,” which is characterized by significant distress and/or functional impairments related to “gender incongruence.”

The DSM-5 is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition—the latest set of criteria used to diagnose mental illness. The addition of distress is important because without distress the panoply of treatments outlined for gender dysphoria aren’t used.

This is one of the most important changes, advocating a variety of expertise brought to bear on gender dysphoria, none of it dedicated to affirming the patient’s wishes:

8. Clarifies the meaning of “multidisciplinary teams” as consisting of a wide range of clinicians with relevant expertise, rather than only “gender dysphoria” specialists

  • The NHS guidance clarifies that a true multidisciplinary team is comprised not only of “gender dysphoria specialists,” but also of experts in pediatrics, autism, neurodisability and mental health, to enable holistic support and appropriate care for gender dysphoric youth.

  • Such multidisciplinary teams will be the hallmark of the new Service, into which challenging and risky cases may be referred. In addition to specific expertise in gender identity development and incongruence, the clinical leadership teams of the newly-established Service will include strong, “consultant level” expertise in a wide range of relevant areas:

    • neurodevelopmental disorders such as autistic spectrum conditions

    • mental health disorders including depressive conditions, anxiety and trauma

    • endocrine conditions including disorders of sexual development pharmacology in the context of gender dysphoria

    • risky behaviors such as deliberate self-harm and substance use

    • complex family contexts including adoptions and guardianships

9. Establishes primary outcome measures of “distress” and “social functioning”

  • The rationale for medical interventions for gender-dysphoric minors has been a moving target, ranging from resolution of gender dysphoria to treatment satisfaction.  The NHS has articulated two main outcome measures of treatment: clinically significant distress and social functioning.

These criteria are used for specifying treatment for other illnesses like depression.

10. Asserts that those who choose to bypass the newly-established protocol will not be supported by the NHS

  • Families and youth planning to obtain hormones directly from online or another external non-NHS source will be strongly advised about the risks.

The NHS will not support further treatment of those who obtain and take hormones outside of the NHS’s protocols.

Can anybody argue that these are not more sensible protocols than the ones used previously? Since most gender dysphoric children turn out to be either cis or gay if not given hormones and surgery, shouldn’t one take these kinds of precautions before injecting or cutting such people?

The premise, of course, is that many children who are dysphoric don’t need “affirmation” (especially if there’s social pressure to change their gender), but compassionate therapy to see how serious their problem is and how strongly they wish to change identity. If you can’t vote until you’re 18, why should you be able to start changing your hormones and body parts before then?  18 is just a subjective age, of course, but the protocol is based on not immediately accepting the views of children—or their parents, who can pressure kids destined to be gay into seeing themselves as transsexuals—that they’re in the wrong body. You don’t just affirm that right off the bat, but ascertain it with intensive therapy.

Of course there will be many objections to these protocols by trans activists who are of the “affirmative care” stripe, but I think that in twenty years we’ll look back on the present as a time when many children were harmed by improper medical and psychological care. That’s the basis of the more than 1,000 lawsuits likely to be filed against Tavistock.

28 thoughts on “National Health Service ends “gender-affirming care,” replaces with “holistic and appropriate” care

  1. The timing of this post is uncanny for me – I’m pausing to read it and then resuming Abigail Shrier’s Irreversible Damage.

    1. And I have to share this — on the page where “Marcus Evans, who resigned from […] the Tavistock Foundation” is quoted.

      1. She’s speaking this evening just a few miles away – I’d have gone but was supposed to be keeping an eye on my dad (he’s 91 and can’t be left alone). I don’t have to now, but the cancellation came too late for me to arrange everything.

        Of course, the Woke students of Cambridge University aren’t happy. They want her to be deplatformed this evening, but are in favour of free speech. Nope, the cognitive dissonance is too much for me as well…!

    2. Ryan Anderson’s When Harry Became Sally (2018), which has been purged from Amazon, is also an interesting analysis of this strange cultural development.

  2. Sadly, the failings at the Tavistock and Portman NHS Trust go far beyond those at the soon-to-be-closed Gender Identity Development Services (GIDS) clinic.

    Nurse and trainee psychotherapist Amy Gallagher is currently bringing a legal case against the Trust for discrimination on the grounds of race and philosophical belief. Here she outlines the shocking way in which she was treated:

  3. One cannot help noticing the simple phonic relationship between these two strings: “affirmative action” and “affirmative care”. Accordingly, I predict that when either of these practices is rejected by authorities, a disguised form of the practice will be slipped through in its place, under the label of “affirmative affirmation”.

  4. One of the major talking points in favor of Affirmative Care — in fact, in favor of transgender doctrine in general — has been the large number of respected organizations who have seemingly all quickly jumped on board. “It must be right or the experts wouldn’t all agree.” It will be interesting to see if this argument gets dropped or minimized as organizations begin to shift their conclusions. Advocates of Affirmation Only should begin to admit that it should be considered at least a somewhat controversial treatment as opposed to the obvious and only reasonable course. We will see.

    This change has effects beyond the medical treatment of children. The popularity of Affirmation Only is driven by the conviction that being trans, like being gay, is an inherent aspect of the core self which is reliably known by the person who says that’s what they are. You’re born that way. Believe the children — and immediately. Would we want to repeat the mistakes we made with homosexuality? Trans kids invariably “knowing who they are”were an important supporting element in this narrative. The NHS policy change clearly isn’t accepting it. That’s not going to go down easily.

    1. This and similar events have greatly harmed my respect for such organizations in recent years. From biological science organizations declaring that biological sex is a spectrum, to the CDC recommending deprioritizing the elderly for COVID treatment even though according to their own models it would significantly increase the number of deaths (which would be a good thing since the elderly are ‘disproportionately white’), to the 1200 public health experts declaring that “we do not condemn these gatherings as risky for COVID-19 transmission” (referring mass BLM protests where thousands of largely unmasked people were yelling in close proximity for hours), to civil rights organizations coming out in favor of censorship, to the general woke takeover of scientific organizations and journals resulting in further censorship and ideologically driven science, to all those medical organizations being totally on board with affirmation-only treatment to transgender feelings, to other examples I could name…

      It’s hard not to assume now that they’re all just partisans and ideologues undeserving of respect or authority.

    2. Although I do believe there is such a thing as gender dysphoria, I do not believe the epidemic of sudden onset gender dysphoria (SOGD), overwhelmingly among middle class white girls, is actual gender dysphoria. As Abigail Shrier pointed out, it might just be a search for victimhood status, which is so eagerly sought after in the ‘Woke Culture’. Who wants to be an ‘oppressor’?

  5. Let’s hope these changes are adopted. It has always been so obvious that “gender-affirming care” would backfire and end up injuring many young people just as they are starting to find their ways in the world.

  6. Remember when lobotomy was a legitimate medical procedure?

    Don’t question it, you just have to trust ‘The Science’

    1. People DID question it. Scientists and MDs. Right from the beginning. It’s why it’s no longer done. What are you trying to say? That science changes with new evidence? That’s a feature not a bug. Or is your point that no one was allowed to question the practice? If so, you’re wrong; they did and that’s why it isn’t being done anymore.

      I guess I am not sure what your point is.

      1. EdwardM, the problem with lobotomy as with gender-affirming care is this: they were adopted (widely practiced) without solid evidence of their therapeutic benefits. This happens much more often than people are aware of and would like to believe. The book to read here is:
        Vinayak K. Prasad & Adam S. Cifu: Ending Medical Reversal: Improving Outcomes, Saving Lives. Johns Hopkins University Press, 2015

        Also interesting:
        David Epstein: When Evidence Says No, But Doctors Say Yes. ProPublica, February 22, 2017
        Years after research contradicts common practices, patients continue to demand them and doctors continue to deliver. The result is an epidemic of unnecessary and unhelpful treatment.

        On lobotomy specifically:
        Paul A. Offit: Pandora’s Lab: Seven Stories of Science Gone Wrong. National Geographic, 2017
        Ch.5 Turning the mind inside out

        1. Thanks for the cites! I do think this is Drew’s point, but wasn’t sure. My troll detection skills are very poor so I sometimes get suspicious.

  7. I say patient affirming care should include facial plastic surgery. Lots of young teens hate their faces, and fear that if they wait until they are adults their faces will be permanently ugly. If doctors regard their patients’ beliefs and emotions so seriously on a matter of such import as sexual identity, why on earth would they have even a moment’s hesitation about performing something so relatively superficial as facial reconstruction?

    I mean, I’d really like to hear a “gender affirming” advocate give a detailed, non-evasive answer to this question.

    1. But it’s doctors who are poisoning and mutilating children. Trust me. I was a doctor. You don’t want to be letting us do that. The politicians have to deliver the corrective when medical judgment fails so abjectly.

      1. The only way people are going to be persuaded by politicians is if there’s a massive bi-partisan effort — and that’s not going to happen. The NHS and Sweden backtracking are impressive because the science is coming through. In the long run, truth will out and it will stick. I don’t think politics should come into this, it’s generally emotion-driven and ham-handed on both sides.

  8. Does anyone think that the US medical-industrial complex will pay any attention to what’s happening in England or Scandinavia? On this side of the pond, virtually every major medical organization is on-board with the affirmative approach (as is the WHO, which doesn’t help the situation at all).

    Gender “care” is a cash cow. Not just for the drug companies, but also for the transition factories and the doctors who are promoting this insane policy. I suspect that the combination of $$$, institutional interests, and professional pride will keep the transition train rolling along until all the wheels fall off.

    Not to mention the Culture War aspect; how likely are the Democrats to reverse course and admit that the Republicans (sort of) are the party of science on this issue? And the woke brownshirts (e.g., Pharyngula) will keep everybody in line… No way is this going to end well in the US.

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