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

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.