29 mars 2024
NHS England will no longer allow puberty blockers for gender dysphoria, while the updated cross-sex hormones policy suggests a move toward caution as the country awaits the final Cass report due April 2024
In March 2024, NHS England (NHSE) updated its puberty blockers and cross-sex hormones policies for gender-dysphoric youth. The release of these policies coincides with the launch of the new service model, which will replace the Gender Identity Development Service (GIDS) at Tavistock as of April 1, 2024. The goal of the new service model is to provide holistic care and support for gender-distressed youth, shifting away from the “gender clinic” model of care focused on gender transition of minors.
NHS England published a total of 11 documents in March 2024 explaining and supporting these changes (10 documents regarding the puberty blocker policy and 1 for the cross-sex hormone policy). Below, we summarize the most salient takeaways of these documents. Further changes are likely after the publication of the final Cass report expected in April 2024.
Puberty blockers (PB) as a treatment for gender dysphoria will no longer be prescribed by NHS England providers as of April 1, 2024. This NHSE Puberty Blockers (PB) policy finalized an earlier draft published in August 2023, which went through a 90-day public consultation period and subsequently underwent further changes. The most salient change in the final document is the removal of the “exceptional circumstances” provision. Under the prior draft, some youth would have been allowed to start PBs if they were deemed “exceptional” cases. This option has been eliminated in the final policy. No child will be initiated on PBs for gender dysphoria outside of an approved clinical trial within the NHSE system.
Cross-sex hormones (CSH) can still be prescribed by the NHS England providers to youth at “around 16 years of age” but with a new safeguarding element. Unlike the PB policy which underwent a lengthy and transparent update that reflected the recommendations of the draft Cass report, the revised CSH policy appears to be a much more hasty update of the 2016 policy, with a significant disconnect from the interim Cass report.
The update eliminated the prior requirement for patients to be on PBs for a year prior to commencing CSH treatment. This update was necessary to synchronize the two NHSE policies, as the prerequisite of PBs no longer makes sense given the NHSE decommissioning of PBs for gender dysphoria. This policy is likely an interim step in time for the launch of the new service on April 1, 2024. Further changes to the CSH policy will likely take place after the final Cass report, which is expected to come out later in April.
Under the current update, youth around the age of 16 can still be prescribed cross-sex hormones, but a new guardrail provision has been added. The policy now explicitly requires that a multidisciplinary team of clinicians “not directly involved in the formation of the individual’s care plan” agree on the appropriateness of the CSH treatment.
Research into puberty blockers is being designed but there is no guarantee that it will gain ethics approval. NHS England accepted the interim Cass report recommendation that young people seeking hormonal interventions should be entered into a research protocol. The NHS appointed a Clinical Trials Unit to develop the research protocol (including eligibility criteria) with the initial focus on puberty blockers for youth with prepubertal onset of gender dysphoria. The process will be overseen by a newly established National Research Oversight Programme Board.
However, the NHS cautioned that such a clinical trial must undergo ethics approval, which is not guaranteed. The NHS made it clear that unless and until the research trial is approved, no child will receive PBs for gender dysphoria from NHS England.
All references to WPATH have been removed from the PB and CSH policies. During the consultation period for the PB policy, WPATH and EPATH issued a joint comment, noting that NHS England deviated from Standard of Care (SOC) 8 and urging it to keep puberty blockers for gender dysphoria available in general clinical use. In response, NHS England thoroughly evaluated the 200 citations in the relevant SOC chapter (i.e., Chapter 12 Hormone Therapy), but found them to be inconsequential.
Neither the PB nor the CSH updated policies contain references to WPATH. Notably, the revised CSH policy specifically removed the prior reference to the WPATH Standards of Care.
Private clinics and providers are exempt from the current policies. While private healthcare is generally uncommon in the UK, this option does exist. Specific to gender services, there is only one private clinic approved by the UK Care Quality Commission (CQC) to provide endocrine interventions for gender dysphoric youth outside the NHS. The clinic, Gender Plus (not to be confused with Gender GP, which is based outside the UK and therefore beyond the reach of UK regulations), currently only sees patients aged 16+ and focuses on cross-sex hormone prescribing.
It is possible that the NHS restrictions on the provisions of PBs and CSHs will result in a proliferation of private gender clinics providing both puberty blockers and cross-sex hormones with far fewer restrictions, as private clinics are not covered by the NHS policies. However, even private clinics are under the purview of the CQC, which suggests at least some level of oversight in the private sector.
The final Cass report is due in April. The interim Cass report has had a profound influence on the structure of gender services in England overall, and on the NHSE PB policy in particular. Thus far, however, it has had almost no influence on the CSH policy, which, despite the recent update, did not fundamentally change the conditions under which CSH are prescribed to gender-dysphoric youth. The final report from Dr. Hilary Cass is expected to be published in April 2024. The report should provide more clarity regarding a number of as yet unanswered questions and is likely to lead to additional policy changes and updates related to cross-sex hormones.
GIDS at the Tavistock will close its doors on March 31, 2024. The initial plan to shut down GIDS at the Tavistock in 2023 was delayed, but at this point, its closure on March 31 is imminent. GIDS will be replaced with a fundamentally new model of care for gender dysphoric youth, which will prioritize psychological and psychotherapeutic exploration and support. Two new service hubs will start operation on April 1, 2024, with several more hubs in the planning stages.
Background
On March 12 2024 NHS England published a new clinical policy for the use of puberty blockers (PBs) as a treatment for gender dysphoria. This was followed by an updated clinical policy for the use of cross-sex hormones (CSH), published on March 21 2024.
NHS England is the coordinating body that organizes healthcare for the 56 million residents of England. It sets policies and commissions services from hundreds of organizations known as NHS Trusts, including those relating to gender dysphoria. The new policy is part of wide-ranging reforms to gender dysphoria services in the UK and will be used in a new gender service for children and adolescents that opens in April 2024. It confirms that "The NHS in England will not prescribe Puberty Suppressing Hormones to children and young people with gender incongruence / dysphoria, from 1 April 2024." However, cross-sex hormone prescriptions for those “around their 16th birthday” will still be allowed, pending the final Cass review, which is expected in April 2024.
In 2020, NHS England established an independent review of its approach to gender dysphoria in the under 18s, chaired by eminent pediatrician Dr Hilary Cass OBE, the former president of the Royal College of Paediatrics and Child Health. This was felt necessary due to the sharp rise in referrals over the previous decade, the marked changes in the types of patients being referred which were not well understood, the scarce and inconclusive evidence to inform clinical decision-making, and the failure of the existing service which had been rated 'inadequate' by its regulator, the Care Quality Commission.
In its interim report and subsequent recommendations, the independent Cass Review called for a fundamentally different approach to the treatment of gender dysphoria in young people, to better meet the holistic needs of young people distressed about their gender, rather than focusing on gender to the exclusion of other problems. In response, NHS England decided to permanently close the world's largest pediatric gender clinic, GIDS (the Gender Identity Development Service), and to establish a new regional service based in children's hospitals.
Two regional hubs will open on 1 April 2024, as “phase 1” in the implementation of this new plan. Both hubs are collaborations between several organizations: the southern hub, based in London (at Great Ormond Street Hospital, Evelina London Children's Hospital and the South London and Maudsley NHS Foundation Trust); and the northern hub (at the Alder Hey Children's NHS Foundation Trust in Liverpool and the Royal Manchester Children's Hospital). Several additional hubs are expected to open in the coming years, including one based in Bristol, plans for which are already being developed.
NHS England’s Puberty Suppressing Hormones Policy, March 2024
On March 12, 2024, NHS England issued its puberty blockers (PB) clinical policy (Puberty Suppressing Hormones Policy), disallowing the use of puberty blockers as a treatment for youth gender dysphoria through the NHS. The policy finalized the earlier August 2023 interim clinical policy, which already stipulated that puberty blockers would not be available as routine treatment for gender dysphoria. It also made some additional changes. We highlight some of the more notable aspects of the policy below.
Is there anything new in the final version of this policy?
The August 2023 draft version of the policy was sent for a 90-day public consultation period. The policy published on 12 March is the final version of that draft, which incorporates all new evidence and feedback. Overall, the final policy confirms the draft proposal’s directive not to prescribe puberty-suppressing hormones to patients in the new service, however there are also various changes.
The most notable change between the draft and the final policy was the removal of the earlier clause that would allow the use of PBs in exceptional cases due to widely held concern that such a policy could not operate “appropriately, effectively and equitably.”
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