There are few details over how new NHS children’s gender services will work when they open next month. The NHS says there will be a seamless move to the new survices for young people currently under the care of the Gender Identity Development Service (Gids), based at London’s Tavistock and Portman NHS Foundation Trust. It’s due to close on 31 March – ending its 35 years history. But it has been unclear how ready the new services will be. Recruitment to new roles has been challenging, and responsibility for the training of those staff was handed over to the Academy of Medical Royal Colleges at the eleventh hour.
While we have known that the aim is for these new services to follow a very different, more holistic model of care, prioritising therapeutic interventions to young people seeking help, it has not been entirely clear whether there will be any access to medical interventions – namely drugs that block a young person’s puberty – when the services open.
Until now. NHS England has confirmed its previous intention that puberty blockers will no longer be prescribed on the NHS for the treatment of gender-related distress. In an area of our healthcare system which has been devoid of some of the core features of standard medical practice for too long, the decision is in line with all other treatments: it’s based on evidence. “We have concluded that there is not enough evidence to support the safety or clinical effectiveness of [puberty blockers] to make the treatment routinely available at this time,” NHSE announced.
At around 4pm on Tuesday NHSE published a raft of documents, setting out their decision in detail, and the rationale behind it. NHSE had made it clear in the past that the only way puberty blockers would be made available following the closure of Gids, was through clinical research, or in “exceptional cases”. That latter route has now been closed, with NHSE saying it would not be workable in practice. Instead, a child who did not meet criteria for any new research trial would need to have a clinician to apply under the NHSE’s standard ‘Individual Funding Request’ process. They would have to demonstrate why they believed the case was exceptional and “why a treatment that is not routinely commissioned by the NHS is an appropriate treatment option”.
Children and young people who are under Gids’s care and have begun treatment with puberty blockers (or hormones) will remain on them. Any child who has been referred by Gids to endocrinologists at University College London Hospital London or Leeds Teaching Hospitals but has not started treatment will also be allowed to do so if they wish.
Puberty blockers will remain available on the NHS for two other purposes: alongside hormones for natal males 16 or older seeking to transition, as “oestrogen alone is insufficient to suppress testosterone levels into the normal range for natal females”, and to treat early or precocious puberty in young children. The latter is the only condition these drugs are licensed for when administered to children.
But there will be no medical pathway offered by the new gender services opening in London and north west England on 1 April. It’s possible that puberty blockers – in this context – will never be available again on the NHS either, for NHSE have made it clear that its decision to end prescribing is “not contingent upon the establishment of a clinical study”. If that study doesn’t get ethical approval, puberty blockers will remain unavailable. Should the relevant approval be granted, it’s hoped that recruitment of eligible young people could begin in late 2024. We’re no closer to knowing what the criteria will be for that study though.
The thorny issue of private providers prescribing puberty blockers remains unaddressed by the announcement. NHS England says it fell outside the scope of its consultation. However, it said that it did not know of any regulated source of blockers outside the NHS and could not support anyone sourcing of them privately because of a lack of sufficient evidence over the “safety and clinical effectiveness” of the drugs.
The announcement has already received a polarising response, which is unsurprising for this hugely divisive topic. There have been celebrations from some, with the government heralding it a “landmark decision” that puts children’s safeguarding back at the heart of medical practice. But, there is dismay from others, who believe that vital care has been taken away from trans people. Regardless of what the evidence says, it seems unlikely that this will be accepted without a fight.
[See also: The case against therapy in schools]
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